Provider Demographics
NPI:1972755320
Name:UIC COLLEGE OF DENTISTRY ORAL PATHOLOGY BIOPSY SERVICE
Entity Type:Organization
Organization Name:UIC COLLEGE OF DENTISTRY ORAL PATHOLOGY BIOPSY SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:C
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MSC FRCDC
Authorized Official - Phone:312-996-1104
Mailing Address - Street 1:801 S PAULINA ST
Mailing Address - Street 2:ROOM 525A (M/C 838)
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-7210
Mailing Address - Country:US
Mailing Address - Phone:312-996-3633
Mailing Address - Fax:312-996-9226
Practice Address - Street 1:801 S PAULINA ST
Practice Address - Street 2:ROOM 525A (M/C 838)
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-7210
Practice Address - Country:US
Practice Address - Phone:312-996-3633
Practice Address - Fax:312-996-9226
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSITY OF ILLINOIS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-16
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL14D0646690291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory