Healthcare Provider Details

I. General information

NPI: 1669620902
Provider Name (Legal Business Name): ORAL & MAXILLOFACIAL SURGERY OF CHICAGO P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2008
Last Update Date: 05/21/2025
Certification Date: 05/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 ORLAND SQUARE DR STE 301
ORLAND PARK IL
60462-6550
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 708-349-4000
  • Fax: 888-334-0111
Mailing address:
  • Phone: 708-425-4301
  • Fax: 888-334-0111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number019027447
License Number StateIL

VIII. Authorized Official

Name: DR. GUNJAN JAIN
Title or Position: MANAGER
Credential: DDS
Phone: 708-425-4301