=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376071720
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STACEY LYNN TINKOFF DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/30/2017
-----------------------------------------------------
Last Update Date | 05/30/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 334 BUSSE HWY
-----------------------------------------------------
City | PARK RIDGE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60068-3251
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-825-4030
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 314 LYNN CT
-----------------------------------------------------
City | DES PLAINES
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60016-2830
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-877-1160
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 019031145
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------