Healthcare Provider Details

I. General information

NPI: 1225258957
Provider Name (Legal Business Name): LINCOLN PARK ORAL & COSMETIC SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2449 N LINCOLN AVE
CHICAGO IL
60614-2414
US

IV. Provider business mailing address

2449 N LINCOLN AVE
CHICAGO IL
60614-2414
US

V. Phone/Fax

Practice location:
  • Phone: 773-327-2400
  • Fax: 773-327-4759
Mailing address:
  • Phone: 773-327-2400
  • Fax: 773-327-4759

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. MARVIN GREENE
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 773-327-2400