Provider Demographics
NPI:1184614224
Name:STOJANOVIC, SASA (DDS)
Entity type:Individual
Prefix:
First Name:SASA
Middle Name:
Last Name:STOJANOVIC
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4901 N KEDZIE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-5009
Mailing Address - Country:US
Mailing Address - Phone:773-509-9200
Mailing Address - Fax:773-509-9247
Practice Address - Street 1:4901 N KEDZIE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-5009
Practice Address - Country:US
Practice Address - Phone:773-509-9200
Practice Address - Fax:773-509-9247
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019023091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9177779Medicaid