Healthcare Provider Details

I. General information

NPI: 1043750714
Provider Name (Legal Business Name): BLOOMINGDALE DENTAL REZ, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2017
Last Update Date: 03/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 TIFFANY PT STE 209
BLOOMINGDALE IL
60108-2916
US

IV. Provider business mailing address

1 TIFFANY PT STE 209
BLOOMINGDALE IL
60108-2916
US

V. Phone/Fax

Practice location:
  • Phone: 630-671-0700
  • Fax: 630-671-0546
Mailing address:
  • Phone: 630-671-0700
  • Fax: 630-671-0546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019029473
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number019023898
License Number StateIL

VIII. Authorized Official

Name: ALEXANDER REZNIKOV
Title or Position: PRESIDENT
Credential: DDS
Phone: 847-877-3570