Provider Demographics
NPI:1063954477
Name:GLEN ELLYN ORTHODONTICS, PC
Entity type:Organization
Organization Name:GLEN ELLYN ORTHODONTICS, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:S
Authorized Official - Last Name:WARDELL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:630-697-0334
Mailing Address - Street 1:45 S PARK BLVD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-6280
Mailing Address - Country:US
Mailing Address - Phone:630-469-6200
Mailing Address - Fax:630-469-6203
Practice Address - Street 1:45 S PARK BLVD
Practice Address - Street 2:SUITE 220
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-6280
Practice Address - Country:US
Practice Address - Phone:630-469-6200
Practice Address - Fax:630-469-6203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-16
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL021.002325261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental