=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336237460
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PETTY & SCHUBERTH LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 305 W 75TH STREET
-----------------------------------------------------
City | WILLOWBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-887-8070
-----------------------------------------------------
Fax | 630-887-0069
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 305 W 75TH STREET
-----------------------------------------------------
City | WILLOWBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-887-8070
-----------------------------------------------------
Fax | 630-887-0069
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. RICHARD A SCHUBERTH
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 630-887-8070
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------