=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114093838
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PAVLETIC PAVLETIC AND VORDERER DDS LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/27/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7600 COLLEGE DR
-----------------------------------------------------
City | PALOS HEIGHTS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60463
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-448-2588
-----------------------------------------------------
Fax | 708-448-5208
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7600 COLLEGE DR
-----------------------------------------------------
City | PALOS HEIGHTS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60463
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-448-2588
-----------------------------------------------------
Fax | 708-448-5208
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CORPORATE PRESIDENT
-----------------------------------------------------
Name | DR. CHRISTOPHER JOSEPH PAVLETIC
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 708-448-2588
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------