Healthcare Provider Details

I. General information

NPI: 1164462362
Provider Name (Legal Business Name): MARTIN J ZIDRON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 07/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21660 W FIELD PKWY SUITE 220
DEER PARK IL
60010-7265
US

IV. Provider business mailing address

21660 W FIELD PKWY SUITE 220
DEER PARK IL
60010-7265
US

V. Phone/Fax

Practice location:
  • Phone: 847-381-0106
  • Fax: 847-381-0265
Mailing address:
  • Phone: 847-381-0106
  • Fax: 847-381-0265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number019-017572
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: