Healthcare Provider Details

I. General information

NPI: 1881182103
Provider Name (Legal Business Name): SAMUEL SKURIE, D.D.S., LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2018
Last Update Date: 06/07/2021
Certification Date: 06/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1770 1ST ST STE 450
HIGHLAND PARK IL
60035-5602
US

IV. Provider business mailing address

170 LAKESIDE PL
HIGHLAND PARK IL
60035-5317
US

V. Phone/Fax

Practice location:
  • Phone: 847-432-0254
  • Fax:
Mailing address:
  • Phone: 847-433-6006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SAMUEL SKURIE
Title or Position: OWNER
Credential:
Phone: 847-432-0254