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General NPI Number Information
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NPI Number | 1164723565
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Entity Type | Organization
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Legal Business Name | ADVANCED IMAGING STUDIO, INC.
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Dates
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Enumeration Date | 11/16/2010
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Last Update Date | 11/16/2010
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Provider Practice Location Address
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Address Line | 4307 N CENTRAL AVE
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City | CHICAGO
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State | IL
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Zip | 60634-1815
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Country | US
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Telephone | 773-283-3232
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Fax | 772-283-3205
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Provider Business Mailing Address
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Address Line | 4307 N CENTRAL AVE
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City | CHICAGO
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State | IL
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Zip | 60634-1815
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Country | US
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Telephone | 773-283-3232
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Fax | 772-283-3205
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Authorized Official
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Title or Position | GENERAL MANAGER
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Name | MR. EROS SANTOS
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Credential |
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Telephone | 773-283-3232
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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 | 319012418
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License Number State | IL
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