Healthcare Provider Details

I. General information

NPI: 1477664332
Provider Name (Legal Business Name): NORTH SUBURBAN ORAL AND MAXILLOFACIAL SURGERY LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 02/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 N WESTMORELAND RD SUITE 208
LAKE FOREST IL
60045-1674
US

IV. Provider business mailing address

900 N WESTMORELAND RD SUITE 208
LAKE FOREST IL
60045-1674
US

V. Phone/Fax

Practice location:
  • Phone: 847-234-3390
  • Fax: 847-234-3391
Mailing address:
  • Phone: 847-234-3390
  • Fax: 847-234-3391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number021000537
License Number StateIL

VIII. Authorized Official

Name: DR. RICHARD P. MARTINO
Title or Position: PRESIDENT
Credential: DDS
Phone: 847-234-3390