Provider Demographics
NPI:1265962674
Name:MODERN DENTAL ON CLARK STREET
Entity type:Organization
Organization Name:MODERN DENTAL ON CLARK STREET
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:
Authorized Official - Last Name:PALELLA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-489-5700
Mailing Address - Street 1:2037 W DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-3157
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:744 N CLARK ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-2525
Practice Address - Country:US
Practice Address - Phone:773-489-5700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-18
Last Update Date:2017-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty
No305R00000XManaged Care OrganizationsPreferred Provider Organization