Provider Demographics
NPI:1942595442
Name:IRVING PARK FAMILY DENTIST
Entity Type:Organization
Organization Name:IRVING PARK FAMILY DENTIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDISON
Authorized Official - Middle Name:A
Authorized Official - Last Name:ISHAYA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-790-4939
Mailing Address - Street 1:3431 W IRVING PARK RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-3217
Mailing Address - Country:US
Mailing Address - Phone:773-790-4939
Mailing Address - Fax:
Practice Address - Street 1:3431 W IRVING PARK RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-3217
Practice Address - Country:US
Practice Address - Phone:773-790-4939
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-13
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019024678122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty