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General NPI Number Information
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NPI Number | 1326498130
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Entity Type | Organization
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Legal Business Name | CHICAGOLAND IMPLANT SPECIALIST LTD
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Dates
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Enumeration Date | 06/13/2016
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Last Update Date | 01/24/2017
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Provider Practice Location Address
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Address Line | 237 S MAIN ST
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City | LOMBARD
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State | IL
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Zip | 60148-2647
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Country | US
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Telephone | 312-533-8489
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Fax |
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Provider Business Mailing Address
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Address Line | 6420 N LEHIGH AVE
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City | CHICAGO
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State | IL
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Zip | 60646-2704
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Country | US
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Telephone | 312-624-9300
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. PAUL S PETRUNGARO
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Credential | DDS
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Telephone | 312-415-7481
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 021001401
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License Number State | IL
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