Provider Demographics
NPI:1104047091
Name:CHICAGO FAMILY DENTAL CENTER PC
Entity type:Organization
Organization Name:CHICAGO FAMILY DENTAL CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:WEGMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-551-0500
Mailing Address - Street 1:55 E WASHINGTON ST STE 2141
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-2294
Mailing Address - Country:US
Mailing Address - Phone:312-551-0500
Mailing Address - Fax:312-372-0165
Practice Address - Street 1:55 E WASHINGTON ST STE 2141
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-2294
Practice Address - Country:US
Practice Address - Phone:312-551-0500
Practice Address - Fax:312-372-0165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty