Provider Demographics
NPI:1699868364
Name:CHICAGO OSTEOPATHIC HOSPITAL DENTAL CLINIC, P.C.
Entity type:Organization
Organization Name:CHICAGO OSTEOPATHIC HOSPITAL DENTAL CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ANA
Authorized Official - Middle Name:C
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-947-4665
Mailing Address - Street 1:1525 E. 53RD ST.
Mailing Address - Street 2:#522
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-4530
Mailing Address - Country:US
Mailing Address - Phone:773-947-4665
Mailing Address - Fax:773-256-2373
Practice Address - Street 1:1525 E. 53RD ST.
Practice Address - Street 2:#522
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-4530
Practice Address - Country:US
Practice Address - Phone:773-947-4665
Practice Address - Fax:773-256-2373
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190226261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL101659Medicaid