Healthcare Provider Details

I. General information

NPI: 1750735759
Provider Name (Legal Business Name): UIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2016
Last Update Date: 04/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 W TAYLOR ST
CHICAGO IL
60612-7232
US

IV. Provider business mailing address

316 COUNTY ROAD 599
MOULTON AL
35650-5700
US

V. Phone/Fax

Practice location:
  • Phone: 866-600-2273
  • Fax:
Mailing address:
  • Phone: 256-606-5080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name: JASMA MCDONALD
Title or Position: PEDIATRIC DENTAL RESIDENCY
Credential:
Phone: 256-606-5080