Healthcare Provider Details

I. General information

NPI: 1861570210
Provider Name (Legal Business Name): DHO GREAT LAKES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

528 W BARRY AVE
CHICAGO IL
60657-5417
US

IV. Provider business mailing address

528 W BARRY AVE
CHICAGO IL
60657-5417
US

V. Phone/Fax

Practice location:
  • Phone: 773-929-8888
  • Fax: 773-439-2300
Mailing address:
  • Phone: 773-929-8888
  • Fax: 773-439-2300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateIL

VIII. Authorized Official

Name: MR. PHILIP C MURPHY
Title or Position: PRESIDENT
Credential:
Phone: 773-929-8888