=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104047091
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHICAGO FAMILY DENTAL CENTER PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 55 E WASHINGTON ST STE 2141
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60602-2294
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-551-0500
-----------------------------------------------------
Fax | 312-372-0165
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 55 E WASHINGTON ST STE 2141
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60602-2294
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-551-0500
-----------------------------------------------------
Fax | 312-372-0165
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. GARY GEORGE WEGMANN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 312-551-0500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------