Healthcare Provider Details

I. General information

NPI: 1669499505
Provider Name (Legal Business Name): EVANSTON PERIODONTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

636 CHURCH ST SUITE # 722
EVANSTON IL
60201-4508
US

IV. Provider business mailing address

636 CHURCH ST SUITE # 722
EVANSTON IL
60201-4508
US

V. Phone/Fax

Practice location:
  • Phone: 847-475-7754
  • Fax: 847-475-4725
Mailing address:
  • Phone: 847-475-7754
  • Fax: 847-475-4725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. ROGER ALBERT NOUNEH
Title or Position: MANAGING MEMBER
Credential: DMD; MS
Phone: 312-927-8882