=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336572031
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AUGUST J. DURSO, JR. DDS, LTD.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2013
-----------------------------------------------------
Last Update Date | 08/16/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1661 FEEHANVILLE DR. STE 420
-----------------------------------------------------
City | MOUNT PROSPECT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60056-6045
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-635-0117
-----------------------------------------------------
Fax | 847-635-8562
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1661 FEEHANVILLE DR. STE 420
-----------------------------------------------------
City | MOUNT PROSPECT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60056-6045
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-635-0117
-----------------------------------------------------
Fax | 847-635-8562
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. AUGUST DURSO JR.
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 847-635-0117
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 019019044
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------