Provider Demographics
NPI:1356411136
Name:WESTCHESTER FAMILY DENTAL LTD
Entity type:Organization
Organization Name:WESTCHESTER FAMILY DENTAL LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAFFAELE
Authorized Official - Middle Name:C
Authorized Official - Last Name:AMBROSINO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:708-562-5621
Mailing Address - Street 1:4 WESTBROOK CORPORATE CENTER STE 102
Mailing Address - Street 2:
Mailing Address - City:WESTCHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:60104
Mailing Address - Country:US
Mailing Address - Phone:708-562-5621
Mailing Address - Fax:708-562-7657
Practice Address - Street 1:4 WESTBROOK CORPORATE CENTER STE 102
Practice Address - Street 2:
Practice Address - City:WESTCHESTER
Practice Address - State:IL
Practice Address - Zip Code:60104
Practice Address - Country:US
Practice Address - Phone:708-562-5621
Practice Address - Fax:708-562-7657
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0250521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty