Provider Demographics
NPI:1992873921
Name:BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS
Entity type:Organization
Organization Name:BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE DEAN FOR PATIENT SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:M
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:BS, MA, DDS
Authorized Official - Phone:312-996-3544
Mailing Address - Street 1:801 S PAULINA ST
Mailing Address - Street 2:MC 621
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-7210
Mailing Address - Country:US
Mailing Address - Phone:312-996-7555
Mailing Address - Fax:312-355-3864
Practice Address - Street 1:801 S PAULINA ST
Practice Address - Street 2:MC 621
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-7210
Practice Address - Country:US
Practice Address - Phone:312-996-7555
Practice Address - Fax:312-355-3864
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-30
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL334470Medicare PIN