Provider Demographics
NPI:1528246212
Name:PROCARE DENTAL GROUP, P.C.
Entity type:Organization
Organization Name:PROCARE DENTAL GROUP, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:G
Authorized Official - Last Name:BRUNETTI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-640-1112
Mailing Address - Street 1:434 W ONTARIO ST
Mailing Address - Street 2:STE 300
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654
Mailing Address - Country:US
Mailing Address - Phone:312-475-9751
Mailing Address - Fax:312-475-9754
Practice Address - Street 1:434 WEST ONTARIO STREET
Practice Address - Street 2:STE 300
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654
Practice Address - Country:US
Practice Address - Phone:847-640-1112
Practice Address - Fax:847-640-1107
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROCARE DENTAL GROUP, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-05
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060-008822122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty