Provider Demographics
NPI:1669529145
Name:THE TOOTH REPAIR SHOPPE, LTD.
Entity type:Organization
Organization Name:THE TOOTH REPAIR SHOPPE, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:C
Authorized Official - Last Name:CALLEIA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:630-682-0844
Mailing Address - Street 1:610 W. ROOSEVELT ROAD
Mailing Address - Street 2:SUITE A1
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187
Mailing Address - Country:US
Mailing Address - Phone:630-682-0844
Mailing Address - Fax:630-682-1428
Practice Address - Street 1:610 W ROOSEVELT RD
Practice Address - Street 2:SUITE A1
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-5087
Practice Address - Country:US
Practice Address - Phone:630-682-0844
Practice Address - Fax:630-682-1428
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0600082571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty