Healthcare Provider Details

I. General information

NPI: 1447388764
Provider Name (Legal Business Name): CLARISSA COUCH DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 04/22/2021
Certification Date: 04/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10220 S 76TH AVE SUITE 250
BRIDGEVIEW IL
60455-2425
US

IV. Provider business mailing address

2020W HARRISON ST
CHICAGO IL
60612-3741
US

V. Phone/Fax

Practice location:
  • Phone: 708-974-6160
  • Fax:
Mailing address:
  • Phone: 312-572-4788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number019022817
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019-022817
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: