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General NPI Number Information
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NPI Number | 1447388764
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Entity Type | Individual
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Provider Name | CLARISSA COUCH DDS
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Gender | Female
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Dates
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Enumeration Date | 02/28/2007
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Last Update Date | 04/22/2021
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Provider Practice Location Address
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Address Line | 10220 S 76TH AVE SUITE 250
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City | BRIDGEVIEW
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State | IL
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Zip | 60455-2425
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Country | US
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Telephone | 708-974-6160
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Fax |
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Provider Business Mailing Address
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Address Line | 2020W HARRISON ST
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City | CHICAGO
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State | IL
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Zip | 60612-3741
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Country | US
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Telephone | 312-572-4788
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223D0001X
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Taxonomy Name | Public Health Dentistry
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License Number | 019022817
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019-022817
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License Number State | IL
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