Healthcare Provider Details

I. General information

NPI: 1396319711
Provider Name (Legal Business Name): SOUTH PARK ORTHO PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2021
Last Update Date: 05/19/2021
Certification Date: 05/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 W TALCOTT RD
PARK RIDGE IL
60068-5408
US

IV. Provider business mailing address

1699 E WOODFIELD RD STE 102
SCHAUMBURG IL
60173-4955
US

V. Phone/Fax

Practice location:
  • Phone: 847-318-7711
  • Fax:
Mailing address:
  • Phone: 630-869-5857
  • 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: ROBERT CORY STITES
Title or Position: INSURANCE COORDINATOR-DECISION ONE
Credential:
Phone: 630-869-5857