Provider Demographics
NPI:1952058257
Name:SWEET TOOTH DOC LTD
Entity Type:Organization
Organization Name:SWEET TOOTH DOC LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARGAUX
Authorized Official - Middle Name:
Authorized Official - Last Name:DEROSSET-GRASON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:773-525-7725
Mailing Address - Street 1:2454 N ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-2021
Mailing Address - Country:US
Mailing Address - Phone:773-525-7725
Mailing Address - Fax:
Practice Address - Street 1:2454 N ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-2021
Practice Address - Country:US
Practice Address - Phone:773-525-7725
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-07
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty