Provider Demographics
NPI:1801150610
Name:CHICAGO DENTAL SALON, P.C.
Entity type:Organization
Organization Name:CHICAGO DENTAL SALON, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:CAMPIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:708-425-2542
Mailing Address - Street 1:10004 S KEDZIE AVE
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-3420
Mailing Address - Country:US
Mailing Address - Phone:708-425-2542
Mailing Address - Fax:
Practice Address - Street 1:10004 S KEDZIE AVE
Practice Address - Street 2:
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-3420
Practice Address - Country:US
Practice Address - Phone:708-425-2542
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-26
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190179311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty