Provider Demographics
NPI:1245858695
Name:VERSIANI DENTAL PC
Entity type:Organization
Organization Name:VERSIANI DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GABRIELA
Authorized Official - Middle Name:
Authorized Official - Last Name:DURAES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:708-834-3602
Mailing Address - Street 1:156 E LAKE ST STE A
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60108-1159
Mailing Address - Country:US
Mailing Address - Phone:630-295-9600
Mailing Address - Fax:
Practice Address - Street 1:2340 N CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-6622
Practice Address - Country:US
Practice Address - Phone:708-834-3602
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-13
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental