Healthcare Provider Details

I. General information

NPI: 1962021139
Provider Name (Legal Business Name): JORDAN ELMOWITZ DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2020
Last Update Date: 09/06/2022
Certification Date: 09/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 W. POLK STREET CLINIC D
CHICAGO IL
60612
US

IV. Provider business mailing address

1900 W POLK STREET CLINIC D
CHICAGO IL
60612
US

V. Phone/Fax

Practice location:
  • Phone: 866-600-2273
  • Fax:
Mailing address:
  • Phone: 917-797-4559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number019032670
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: