Healthcare Provider Details

I. General information

NPI: 1245741768
Provider Name (Legal Business Name): UDELSON ELMHURST LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2017
Last Update Date: 07/17/2024
Certification Date: 02/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 N YORK ST
ELMHURST IL
60126-2319
US

IV. Provider business mailing address

323 N YORK ST
ELMHURST IL
60126-2319
US

V. Phone/Fax

Practice location:
  • Phone: 630-833-1166
  • Fax:
Mailing address:
  • Phone: 630-833-1166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number021001495
License Number StateIL

VIII. Authorized Official

Name: JERRY UDELSON
Title or Position: OWNER
Credential: DDS
Phone: 630-833-1166