=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205133527
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOSTER AVENUE DENTAL CLINIC P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2011
-----------------------------------------------------
Last Update Date | 02/23/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1400 E GOLF RD SUITE 125
-----------------------------------------------------
City | DES PLAINES
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60016-1236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-827-7990
-----------------------------------------------------
Fax | 847-827-7852
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3318 W FOSTER AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60625-4813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-463-8860
-----------------------------------------------------
Fax | 773-463-9146
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. GREGORY H TIETZER
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 773-463-8860
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 019019206
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------