Provider Demographics
NPI:1922184621
Name:CHICAGO DENTISTS
Entity Type:Organization
Organization Name:CHICAGO DENTISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:NOEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KORENGOLD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-870-4646
Mailing Address - Street 1:2120 NICOLLET AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-2528
Mailing Address - Country:US
Mailing Address - Phone:612-870-4646
Mailing Address - Fax:612-870-7870
Practice Address - Street 1:2120 NICOLLET AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-2528
Practice Address - Country:US
Practice Address - Phone:612-870-4646
Practice Address - Fax:612-870-7870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN91641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN408522100Medicaid