Basic Information
| Provider Information | |||||||||
| NPI: | 1427105139 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHWESTERN DENTAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 E HURON ST | ||||||||
| Address2: | GALTER PAVILION, 2-246 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606113197 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129263264 | ||||||||
| FaxNumber: | 3129263885 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 E HURON ST | ||||||||
| Address2: | GALTER PAVILION, 2-246 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606113197 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129263264 | ||||||||
| FaxNumber: | 3129263885 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HURST | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
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| AuthorizedOfficialTitleorPosition: | TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 3129263264 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MS, BDS, LDS, FDS, | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.