Healthcare Provider Details

I. General information

NPI: 1174651459
Provider Name (Legal Business Name): NORTHSHORE METROPOLITAN DENTAL ASSOCIATES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 08/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1790 NATIONS DR SUITE 212
GURNEE IL
60031-9164
US

IV. Provider business mailing address

1790 NATIONS DR SUITE 212
GURNEE IL
60031-9164
US

V. Phone/Fax

Practice location:
  • Phone: 847-336-4880
  • Fax:
Mailing address:
  • Phone: 847-336-4880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019025154
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. VICTOR KA-TAI LAU
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 847-673-6770