Healthcare Provider Details

I. General information

NPI: 1215123187
Provider Name (Legal Business Name): SOUTHWEST ORAL SURGEONS,P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2007
Last Update Date: 09/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6305 W 95TH ST 3RD FLOOR
OAK LAWN IL
60453-2255
US

IV. Provider business mailing address

6305 W 95TH ST 3RD FLOOR
OAK LAWN IL
60453-2255
US

V. Phone/Fax

Practice location:
  • Phone: 708-425-4300
  • Fax: 708-425-4310
Mailing address:
  • Phone: 708-425-4300
  • Fax: 708-425-4310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. WILLIAM G. FLICK
Title or Position: DOCTOR/OWNER
Credential: DDSMPH
Phone: 708-425-4300