Healthcare Provider Details

I. General information

NPI: 1679761969
Provider Name (Legal Business Name): MIDWEST ORAL AND MAXILLOFACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2007
Last Update Date: 10/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7400 W COLLEGE DR
PALOS HEIGHTS IL
60463-1155
US

IV. Provider business mailing address

7400 W COLLEGE DR
PALOS HEIGHTS IL
60463-1155
US

V. Phone/Fax

Practice location:
  • Phone: 708-448-8670
  • Fax: 708-448-8698
Mailing address:
  • Phone: 708-448-8670
  • Fax: 708-448-8698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MRS. SHEILA M DALY
Title or Position: OFFICE MANAGER
Credential:
Phone: 708-448-8670