Healthcare Provider Details

I. General information

NPI: 1821241290
Provider Name (Legal Business Name): OTRAGEN ORTHODONTICS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2008
Last Update Date: 12/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 SHERMER RD SUITE #100
NORTHBROOK IL
60062-5340
US

IV. Provider business mailing address

1500 SHERMER RD SUITE #100
NORTHBROOK IL
60062-5340
US

V. Phone/Fax

Practice location:
  • Phone: 224-223-8116
  • Fax:
Mailing address:
  • Phone: 224-223-8116
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: EDNA DOYLA
Title or Position: TREATMENT COORDINATOR
Credential:
Phone: 224-223-8116