Healthcare Provider Details

I. General information

NPI: 1366599748
Provider Name (Legal Business Name): CHICAGO ORAL & MAXILLOFACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 05/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

676 N ST. CLAIR STREET SUITE 2280
CHICAGO IL
60611-3197
US

IV. Provider business mailing address

676 N ST. CLAIR STREET SUITE 2280
CHICAGO IL
60611-3197
US

V. Phone/Fax

Practice location:
  • Phone: 312-926-2929
  • Fax: 312-926-3595
Mailing address:
  • Phone: 312-926-2929
  • Fax: 312-926-3595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number21-001074
License Number StateIL

VIII. Authorized Official

Name: DR. NEIL BRUCE HAGEN
Title or Position: OWNER
Credential: DDS
Phone: 312-926-2929