Provider Demographics
NPI:1316079502
Name:STORM, DAVID JAMES (DDS)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:JAMES
Last Name:STORM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:174 W SAUK TRL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60411-5359
Mailing Address - Country:US
Mailing Address - Phone:708-755-2042
Mailing Address - Fax:708-755-2056
Practice Address - Street 1:174 W SAUK TRL
Practice Address - Street 2:
Practice Address - City:CHICAGO HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60411-5359
Practice Address - Country:US
Practice Address - Phone:708-755-2042
Practice Address - Fax:708-755-2056
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice