Provider Demographics
NPI:1457775710
Name:ALLCARE ORTHODONTIC CENTER LLC
Entity Type:Organization
Organization Name:ALLCARE ORTHODONTIC CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BUDI
Authorized Official - Middle Name:
Authorized Official - Last Name:KUSNOTO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:312-804-8304
Mailing Address - Street 1:47 W POLK ST STE 251
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-2000
Mailing Address - Country:US
Mailing Address - Phone:312-804-8304
Mailing Address - Fax:312-873-3803
Practice Address - Street 1:842 W 31ST ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-5837
Practice Address - Country:US
Practice Address - Phone:312-804-8304
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-07
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190268241223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty