=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194998401
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TOOTH FAIRY DENTAL PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/08/2008
-----------------------------------------------------
Last Update Date | 04/08/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 333 W. NORTH AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-751-1113
-----------------------------------------------------
Fax | 312-751-1116
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 333 W NORTH AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60610-1293
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-751-1113
-----------------------------------------------------
Fax | 312-751-1116
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | GENERAL DENTIST
-----------------------------------------------------
Name | SASA STOJANOVIC
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 312-751-1113
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------