Provider Demographics
NPI:1124245527
Name:CHILDREN'S DENTISTRY OF LAKE COUNTY AND ASSOCIATES, P.C.
Entity type:Organization
Organization Name:CHILDREN'S DENTISTRY OF LAKE COUNTY AND ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:S
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-662-7755
Mailing Address - Street 1:5250 GRAND AVE STE 7
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-1877
Mailing Address - Country:US
Mailing Address - Phone:847-662-7755
Mailing Address - Fax:847-662-7723
Practice Address - Street 1:5250 GRAND AVE STE 7
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-1877
Practice Address - Country:US
Practice Address - Phone:847-662-7755
Practice Address - Fax:847-662-7723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0210017821223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty