Provider Demographics
NPI:1932373206
Name:MARK J. GRUNBERG, D.D.S.
Entity Type:Organization
Organization Name:MARK J. GRUNBERG, D.D.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRACTITIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:J
Authorized Official - Last Name:GRUNBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-276-6600
Mailing Address - Street 1:3758 W CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60651-3823
Mailing Address - Country:US
Mailing Address - Phone:773-276-6600
Mailing Address - Fax:773-276-6600
Practice Address - Street 1:3758 W CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60651-3823
Practice Address - Country:US
Practice Address - Phone:773-276-6600
Practice Address - Fax:773-276-6600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-17
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental