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General NPI Number Information
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NPI Number | 1144693748
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Entity Type | Organization
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Legal Business Name | COMPASS DENTAL OF LINCOLN SQUARE
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Dates
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Enumeration Date | 11/04/2015
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Last Update Date | 11/04/2015
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Provider Practice Location Address
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Address Line | 2334 W LAWRENCE AVE STE 215
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City | CHICAGO
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State | IL
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Zip | 60625-1036
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Country | US
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Telephone | 773-561-5747
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Fax |
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Provider Business Mailing Address
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Address Line | 2334 W LAWRENCE AVE STE 215
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City | CHICAGO
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State | IL
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Zip | 60625-1036
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. BRANDON R PRUSA
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Credential | D.D.S.
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Telephone | 773-525-2011
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019028511
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License Number State | IL
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