Healthcare Provider Details

I. General information

NPI: 1124629514
Provider Name (Legal Business Name): CHICAGO PEDIATRIC DENTISTRY AND ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2020
Last Update Date: 11/03/2020
Certification Date: 11/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1136 S DELANO CT W STE B202
CHICAGO IL
60605-3734
US

IV. Provider business mailing address

1136 S DELANO CT W STE B202
CHICAGO IL
60605-3734
US

V. Phone/Fax

Practice location:
  • Phone: 312-766-0995
  • Fax:
Mailing address:
  • Phone: 312-766-0995
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. JUSTIN WELKE
Title or Position: OWNER
Credential: DDS
Phone: 630-886-1780