Healthcare Provider Details

I. General information

NPI: 1457775710
Provider Name (Legal Business Name): ALLCARE ORTHODONTIC CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2014
Last Update Date: 02/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

842 W 31ST ST
CHICAGO IL
60608-5837
US

IV. Provider business mailing address

47 W POLK ST STE 251
CHICAGO IL
60605-2000
US

V. Phone/Fax

Practice location:
  • Phone: 312-804-8304
  • Fax:
Mailing address:
  • Phone: 312-804-8304
  • Fax: 312-873-3803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number019026824
License Number StateIL

VIII. Authorized Official

Name: DR. BUDI KUSNOTO
Title or Position: PRESIDENT
Credential: DDS, MS
Phone: 312-804-8304