Healthcare Provider Details

I. General information

NPI: 1982822912
Provider Name (Legal Business Name): ORAL AND MAXILLOFACIAL SURGERY AFFILIATES LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 S WASHINGTON ST. STE 101
PARK RIDGE IL
60068-4203
US

IV. Provider business mailing address

111 S WASHINGTON AVE STE 101
PARK RIDGE IL
60068-4203
US

V. Phone/Fax

Practice location:
  • Phone: 847-696-4848
  • Fax: 847-696-1609
Mailing address:
  • Phone: 847-696-4848
  • Fax: 847-696-1609

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. JOHN MICHAEL SISTO
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 847-696-4848