Healthcare Provider Details

I. General information

NPI: 1982976643
Provider Name (Legal Business Name): IRVING PARK PERIODONTICS, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2012
Last Update Date: 01/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4949 W IRVING PARK RD STE. D
CHICAGO IL
60641-2655
US

IV. Provider business mailing address

4949 W IRVING PARK RD STE. D
CHICAGO IL
60641-2655
US

V. Phone/Fax

Practice location:
  • Phone: 773-794-1332
  • Fax: 773-794-1032
Mailing address:
  • Phone: 773-794-1332
  • Fax: 773-794-1032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number021001422
License Number StateIL

VIII. Authorized Official

Name: DR. THOMAS FREDERIC SCHNEIDER JR.
Title or Position: PRESIDENT
Credential: DDS
Phone: 773-794-1332