Healthcare Provider Details

I. General information

NPI: 1265836092
Provider Name (Legal Business Name): ORTHODONTIC EXPERTS WEST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2014
Last Update Date: 10/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4709 N HARLEM AVE
HARDWOOD HEIGHTS IL
60706
US

IV. Provider business mailing address

4709 N HARLEM AVE
HARWOOD HEIGHTS IL
60706-4606
US

V. Phone/Fax

Practice location:
  • Phone: 847-691-9401
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number021.002488
License Number StateIL

VIII. Authorized Official

Name: YAROSLAV YARMOLYUK
Title or Position: ORTHODONTIST
Credential: DDS , MS
Phone: 847-691-9401