Provider Demographics
NPI:1912699471
Name:VICTOR, LAITH (DMD)
Entity Type:Individual
Prefix:
First Name:LAITH
Middle Name:
Last Name:VICTOR
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 W ERIE ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-7290
Mailing Address - Country:US
Mailing Address - Phone:248-953-1211
Mailing Address - Fax:
Practice Address - Street 1:4450 N HARLEM AVE
Practice Address - Street 2:
Practice Address - City:NORRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60706-4745
Practice Address - Country:US
Practice Address - Phone:708-402-9135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-23
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.034154122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist