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General NPI Number Information
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NPI Number | 1245741578
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Entity Type | Organization
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Legal Business Name | CHICAGO MALL DENTAL ASSOCIATES, LLC
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Dates
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Enumeration Date | 10/13/2017
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Last Update Date | 10/13/2017
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Provider Practice Location Address
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Address Line | 7501 W CERMAK RD STE F16
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City | NORTH RIVERSIDE
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State | IL
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Zip | 60546-2815
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Country | US
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Telephone | 708-402-8001
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Fax |
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Provider Business Mailing Address
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Address Line | 7501 W CERMAK RD STE F16
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City | NORTH RIVERSIDE
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State | IL
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Zip | 60546-2815
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Country | US
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Telephone | 708-402-8001
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | ROSTISLAV KRASNOV
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Credential |
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Telephone | 786-475-7600
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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 |
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License Number State | IL
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