Provider Demographics
NPI:1306805726
Name:GRAYSLAKE ORTHODONTICS INC
Entity type:Organization
Organization Name:GRAYSLAKE ORTHODONTICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DON
Authorized Official - Middle Name:
Authorized Official - Last Name:FRISKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-548-4330
Mailing Address - Street 1:160 COMMERCE DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-1601
Mailing Address - Country:US
Mailing Address - Phone:847-548-4330
Mailing Address - Fax:847-548-4335
Practice Address - Street 1:160 COMMERCE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-1601
Practice Address - Country:US
Practice Address - Phone:847-548-4330
Practice Address - Fax:847-548-4335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty