Healthcare Provider Details

I. General information

NPI: 1316935232
Provider Name (Legal Business Name): NANCY LEE GOODARE-ROSENTHAL DDS, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NANCY LEE GOODARE DDS,MS

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 10/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 N HARBOR DR APT 2409
CHICAGO IL
60601-5007
US

IV. Provider business mailing address

155 N HARBOR DR
CHICAGO IL
60601-7364
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-7546
  • Fax: 312-355-4173
Mailing address:
  • Phone: 719-588-3146
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019.030532
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number8414
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: