Basic Information
| Provider Information | |||||||||
| NPI: | 1538571591 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | D2 DENTAL AT OAK STREET, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 137 N OAK PARK AVE | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | OAK PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 603011344 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3348 W 87TH ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606523767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7737764471 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2014 | ||||||||
| LastUpdateDate: | 07/23/2014 | ||||||||
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| AuthorizedOfficialLastName: | LABINOV | ||||||||
| AuthorizedOfficialFirstName: | BORIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | AGENT | ||||||||
| AuthorizedOfficialTelephone: | 7084452668 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.