Provider Demographics
NPI:1649496514
Name:PINE DENTAL CARE
Entity type:Organization
Organization Name:PINE DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:STANLEY
Authorized Official - Last Name:CZEREPAK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:773-880-5455
Mailing Address - Street 1:2536 N LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-2889
Mailing Address - Country:US
Mailing Address - Phone:773-880-5455
Mailing Address - Fax:773-880-5809
Practice Address - Street 1:2536 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-2889
Practice Address - Country:US
Practice Address - Phone:773-880-5455
Practice Address - Fax:773-880-5809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty