=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053209197
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PURE DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2025
-----------------------------------------------------
Last Update Date | 06/26/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12040 S HARLEM AVE
-----------------------------------------------------
City | PALOS HEIGHTS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60463-1141
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-448-5675
-----------------------------------------------------
Fax | 708-448-5514
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12040 S HARLEM AVE
-----------------------------------------------------
City | PALOS HEIGHTS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60463-1141
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-448-5675
-----------------------------------------------------
Fax | 708-448-5514
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST/OWNER
-----------------------------------------------------
Name | DR. PATRICIA GENNARO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 708-448-5675
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------