Provider Demographics
NPI:1912136623
Name:MONTROSE DENTAL CLINIC PC
Entity Type:Organization
Organization Name:MONTROSE DENTAL CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:FANG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-969-0198
Mailing Address - Street 1:3541 W. MONTROSE AVE
Mailing Address - Street 2:UNIT 1W
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618
Mailing Address - Country:US
Mailing Address - Phone:773-463-8000
Mailing Address - Fax:773-463-8001
Practice Address - Street 1:3541 W. MONTROSE AVE
Practice Address - Street 2:UNIT 1W
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618
Practice Address - Country:US
Practice Address - Phone:773-463-8000
Practice Address - Fax:773-463-8001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-02
Last Update Date:2009-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019025991122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty