Basic Information
| Provider Information | |||||||||
| NPI: | 1992794598 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSENTHAL | ||||||||
| FirstName: | MARC | ||||||||
| MiddleName: | |||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 641 W 63RD ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606212032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195895161 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 641 W 63RD ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606212032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195895161 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2005 | ||||||||
| LastUpdateDate: | 07/20/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 8416 | CO | N | Dental Providers | Dentist | 1223G0001X | 019.030533 | IL | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 27839770 | 05 | CO | MEDICAID | 16678028 | 01 | NEW MEXICO MEDICAID | OTHER | 019030533 | 05 | IL | MEDICAID | 840706945138 | 01 | CO | ROCKY MOUNTAIN HEALTH PLA | OTHER |