Provider Demographics
NPI:1932322021
Name:NORTH SUBURBAN ENDODONTICS PC
Entity Type:Organization
Organization Name:NORTH SUBURBAN ENDODONTICS PC
Other - Org Name:DR KERMIT RADKE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ENDODONTIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KERMIT
Authorized Official - Middle Name:MASON
Authorized Official - Last Name:RADKE
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:847-623-4910
Mailing Address - Street 1:4165 OLD GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031
Mailing Address - Country:US
Mailing Address - Phone:847-623-4910
Mailing Address - Fax:847-623-6054
Practice Address - Street 1:4165 OLD GRAND AVE
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031
Practice Address - Country:US
Practice Address - Phone:847-623-4910
Practice Address - Fax:847-623-6054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty