Healthcare Provider Details

I. General information

NPI: 1003962192
Provider Name (Legal Business Name): WICKER PARK DENTAL, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 02/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1738 W NORTH AVE
CHICAGO IL
60622
US

IV. Provider business mailing address

1738 W. NORTH AVE
CHICAGO IL
60622
US

V. Phone/Fax

Practice location:
  • Phone: 773-276-5566
  • Fax: 773-276-8780
Mailing address:
  • Phone: 773-276-5566
  • Fax: 773-276-8780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number060010054
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NIDZA ALICEA
Title or Position: OFFICE MANAGER
Credential:
Phone: 773-235-0980