Healthcare Provider Details

I. General information

NPI: 1073991162
Provider Name (Legal Business Name): REZNIKOV DENTAL, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2015
Last Update Date: 05/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1556 S MICHIGAN AVE STE 110
CHICAGO IL
60605-1937
US

IV. Provider business mailing address

1556 S MICHIGAN AVE STE 110
CHICAGO IL
60605
US

V. Phone/Fax

Practice location:
  • Phone: 312-588-0043
  • Fax: 312-588-0287
Mailing address:
  • Phone: 312-588-0043
  • Fax: 312-588-0287

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 Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. ALEXANDER REZNIKOV
Title or Position: OWNER/DENTIST
Credential: DDS
Phone: 847-877-3570