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General NPI Number Information
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NPI Number | 1144765777
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Entity Type | Organization
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Legal Business Name | BLUE STAR DENTAL INC
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Dates
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Enumeration Date | 01/06/2017
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Last Update Date | 01/06/2017
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Provider Practice Location Address
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Address Line | 4703 W LAWRENCE AVE
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City | CHICAGO
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State | IL
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Zip | 60630-1722
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Country | US
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Telephone | 773-698-5773
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Fax |
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Provider Business Mailing Address
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Address Line | 5711 N KIMBALL AVE APT 1N
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City | CHICAGO
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State | IL
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Zip | 60659-4523
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Country | US
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Telephone | 773-698-5773
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | DORINA NASTASE
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Credential | DMD
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Telephone | 773-698-5773
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 019030349
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License Number State | IL
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