Provider Demographics
NPI:1013480755
Name:PEDIATRIC DENTAL SURGICAL ASSOCIATES PLLC
Entity Type:Organization
Organization Name:PEDIATRIC DENTAL SURGICAL ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHNNY
Authorized Official - Middle Name:
Authorized Official - Last Name:KUTTAB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-423-6050
Mailing Address - Street 1:2550 W ADDISON ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-5952
Mailing Address - Country:US
Mailing Address - Phone:773-423-6050
Mailing Address - Fax:
Practice Address - Street 1:2550 W ADDISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-5952
Practice Address - Country:US
Practice Address - Phone:773-423-6050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-04
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty