Provider Demographics
NPI:1932416898
Name:BRIDGEPORT DENTAL SPECIALISTS LLC
Entity Type:Organization
Organization Name:BRIDGEPORT DENTAL SPECIALISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:VONGLUEKIAT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-791-0920
Mailing Address - Street 1:2959 S WALLACE ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-3034
Mailing Address - Country:US
Mailing Address - Phone:312-791-0920
Mailing Address - Fax:312-842-5338
Practice Address - Street 1:2959 S WALLACE ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-3034
Practice Address - Country:US
Practice Address - Phone:312-791-0920
Practice Address - Fax:312-842-5338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-13
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190276521223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty