Provider Demographics
NPI:1366064594
Name:MY GERIATRIC DENTIST
Entity type:Organization
Organization Name:MY GERIATRIC DENTIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLUMOFE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-590-1880
Mailing Address - Street 1:2093 RAND RD
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-4727
Mailing Address - Country:US
Mailing Address - Phone:847-590-1880
Mailing Address - Fax:708-590-0868
Practice Address - Street 1:2093 RAND RD
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016-4727
Practice Address - Country:US
Practice Address - Phone:847-590-1880
Practice Address - Fax:708-590-0868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-11
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty