Healthcare Provider Details

I. General information

NPI: 1275740367
Provider Name (Legal Business Name): JOVAN CUPIC D.M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8800 LOCKWOOD AVE STE C
SKOKIE IL
60077-1500
US

IV. Provider business mailing address

8800 LOCKWOOD AVE STE C
SKOKIE IL
60077-1500
US

V. Phone/Fax

Practice location:
  • Phone: 847-965-8780
  • Fax: 847-967-1429
Mailing address:
  • Phone: 847-965-8780
  • Fax: 847-967-1429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number19A14032
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: