Provider Demographics
NPI:1669909370
Name:DENTAL ASSOCIATES OF ALSIP, LLC
Entity type:Organization
Organization Name:DENTAL ASSOCIATES OF ALSIP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:GRUENEBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-778-5274
Mailing Address - Street 1:3333 N MAYFAIR RD
Mailing Address - Street 2:SUITE 311
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53222-3219
Mailing Address - Country:US
Mailing Address - Phone:414-808-3031
Mailing Address - Fax:414-808-3098
Practice Address - Street 1:5061 WEST 111TH ST.
Practice Address - Street 2:
Practice Address - City:ALSIP
Practice Address - State:IL
Practice Address - Zip Code:60803-6074
Practice Address - Country:US
Practice Address - Phone:708-422-6655
Practice Address - Fax:708-422-0628
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-12
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty