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General NPI Number Information
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NPI Number | 1013075480
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Entity Type | Organization
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Legal Business Name | ENDODONTIC & PERIODONTIC ASSOCIATES, LTD
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Dates
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Enumeration Date | 12/05/2006
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Last Update Date | 10/17/2014
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Provider Practice Location Address
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Address Line | 18130 HALSTED ST
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City | HOMEWOOD
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State | IL
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Zip | 60430-2507
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Country | US
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Telephone | 708-799-2550
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Fax | 708-799-2568
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Provider Business Mailing Address
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Address Line | 18130 HALSTED ST
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City | HOMEWOOD
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State | IL
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Zip | 60430-2507
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Country | US
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Telephone | 708-799-2550
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Fax | 708-799-2568
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Authorized Official
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Title or Position | COO & PRACTICE ADMINISTRATOR
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Name | MR. J. MICHAEL CVENGROS
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Credential |
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Telephone | 708-922-1165
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 060000064
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 1223E0200X
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Taxonomy Name | Endodontics
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License Number | 060000064
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License Number State | IL
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