Provider Demographics
NPI:1154112472
Name:RAVENSWOOD DENTAL PLLC
Entity type:Organization
Organization Name:RAVENSWOOD DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:
Authorized Official - Last Name:SIEGEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-772-8400
Mailing Address - Street 1:1440 SHERIDAN RD UNIT UL102
Mailing Address - Street 2:
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-1838
Mailing Address - Country:US
Mailing Address - Phone:847-648-1980
Mailing Address - Fax:
Practice Address - Street 1:5015 N PAULINA ST STE 330
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-2756
Practice Address - Country:US
Practice Address - Phone:773-774-3555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-15
Last Update Date:2025-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental