Provider Demographics
NPI:1316074818
Name:SUBURBAN FAMILY DENTAL CENTER, INC.
Entity type:Organization
Organization Name:SUBURBAN FAMILY DENTAL CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LOIDA
Authorized Official - Middle Name:TICZON
Authorized Official - Last Name:PREZA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:773-769-8195
Mailing Address - Street 1:5214 N WESTERN AVE
Mailing Address - Street 2:SUITE 303
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-2589
Mailing Address - Country:US
Mailing Address - Phone:773-769-8195
Mailing Address - Fax:
Practice Address - Street 1:5214 N WESTERN AVE
Practice Address - Street 2:SUITE 303
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-2589
Practice Address - Country:US
Practice Address - Phone:773-769-8195
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2012-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190229551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty