Provider Demographics
NPI:1205095387
Name:THE CENTER FOR ORAL, MAXILLOFACIAL & IMPLANT SURGERY
Entity type:Organization
Organization Name:THE CENTER FOR ORAL, MAXILLOFACIAL & IMPLANT SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:WALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-869-1080
Mailing Address - Street 1:500 DAVIS ST 509
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201
Mailing Address - Country:US
Mailing Address - Phone:847-869-9303
Mailing Address - Fax:847-869-9323
Practice Address - Street 1:500 DAVIS ST 509
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201
Practice Address - Country:US
Practice Address - Phone:847-869-9303
Practice Address - Fax:847-869-9323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-04
Last Update Date:2025-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060.001866021.0011941223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL525690Medicare PIN
IL661860Medicare PIN
IL69656019Medicare PIN