Healthcare Provider Details

I. General information

NPI: 1265962674
Provider Name (Legal Business Name): MODERN DENTAL ON CLARK STREET
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2017
Last Update Date: 06/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

744 N CLARK ST
CHICAGO IL
60654-2525
US

IV. Provider business mailing address

2037 W DIVISION ST
CHICAGO IL
60622-3157
US

V. Phone/Fax

Practice location:
  • Phone: 773-489-5700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number
License Number State

VIII. Authorized Official

Name: DR. PHILLIP PALELLA
Title or Position: OWNER
Credential: DDS
Phone: 773-489-5700