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General NPI Number Information
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NPI Number | 1013068972
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Entity Type | Organization
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Legal Business Name | CITY KIDS DENTAL, PC
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Dates
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Enumeration Date | 01/16/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 4700 N WESTERN AVE SUITE 1A
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City | CHICAGO
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State | IL
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Zip | 60625-2081
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Country | US
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Telephone | 773-293-2700
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Fax | 773-293-3854
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Provider Business Mailing Address
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Address Line | 4700 N WESTERN AVE SUITE 1A
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City | CHICAGO
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State | IL
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Zip | 60625-2081
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Country | US
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Telephone | 773-293-2700
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Fax | 773-293-3854
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MARY ELIZABETH TIERNEY
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Credential | D.D.S., M.S.
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Telephone | 773-293-2700
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State | IL
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