Provider Demographics
NPI:1922527852
Name:STONY ISLAND DENTALWORKS LLC
Entity Type:Organization
Organization Name:STONY ISLAND DENTALWORKS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:REGINALD
Authorized Official - Middle Name:TORRANCE
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-493-4937
Mailing Address - Street 1:56 E 47TH ST STE 200
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60653-3982
Mailing Address - Country:US
Mailing Address - Phone:773-858-7481
Mailing Address - Fax:773-675-4419
Practice Address - Street 1:2235 E 71ST ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60649-2539
Practice Address - Country:US
Practice Address - Phone:773-493-4937
Practice Address - Fax:773-675-4419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-12
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19-025166122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty