Healthcare Provider Details

I. General information

NPI: 1851219760
Provider Name (Legal Business Name): ETHAN DANIEL SPRING
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2026
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

712 E 87TH ST
CHICAGO IL
60619-6246
US

IV. Provider business mailing address

165 N DESPLAINES ST
CHICAGO IL
60661-1446
US

V. Phone/Fax

Practice location:
  • Phone: 773-783-9000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019.037351
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: