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General NPI Number Information
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NPI Number | 1205087285
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Entity Type | Organization
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Legal Business Name | OPTIMUM DENTAL CENTER, PC
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Dates
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Enumeration Date | 10/08/2008
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Last Update Date | 10/08/2008
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Provider Practice Location Address
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Address Line | 11076 S. LONGWOOD DR.
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City | CHICAGO
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State | IL
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Zip | 60643
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Country | US
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Telephone | 773-239-7258
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Fax | 773-239-7259
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Provider Business Mailing Address
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Address Line | 11076 S. LONGWOOD DR.
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City | CHICAGO
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State | IL
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Zip | 60643
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Country | US
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Telephone | 773-239-7258
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Fax | 773-239-7259
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Authorized Official
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Title or Position | OWNER/DENTIST
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Name | DR. DEBORAH ANN MONTGOMERY
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Credential | DDS
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Telephone | 773-239-7258
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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 | 019-022902
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License Number State | IL
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