Healthcare Provider Details

I. General information

NPI: 1609456771
Provider Name (Legal Business Name): STEPHEN THOMAS TREACY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2021
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 S PAULINA ST RM 131
CHICAGO IL
60612-7210
US

IV. Provider business mailing address

801 S PAULINA ST RM 131
CHICAGO IL
60612-7210
US

V. Phone/Fax

Practice location:
  • Phone: 860-372-0515
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number13650
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number10725
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019033126
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: