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General NPI Number Information
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NPI Number | 1124245527
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Entity Type | Organization
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Legal Business Name | CHILDREN'S DENTISTRY OF LAKE COUNTY AND ASSOCIATES, P.C.
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Dates
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Enumeration Date | 04/19/2007
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Last Update Date | 08/01/2008
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Provider Practice Location Address
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Address Line | 5250 GRAND AVE STE 7
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City | GURNEE
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State | IL
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Zip | 60031-1877
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Country | US
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Telephone | 847-662-7755
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Fax | 847-662-7723
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Provider Business Mailing Address
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Address Line | 5250 GRAND AVE STE 7
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City | GURNEE
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State | IL
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Zip | 60031-1877
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Country | US
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Telephone | 847-662-7755
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Fax | 847-662-7723
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. CHRISTINE S LEE
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Credential | D.D.S.
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Telephone | 847-662-7755
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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 | 021001782
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License Number State | IL
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