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General NPI Number Information
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NPI Number | 1447706494
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Entity Type | Organization
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Legal Business Name | CUSP DENTAL STUDIO PC
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Dates
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Enumeration Date | 08/30/2016
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Last Update Date | 08/30/2016
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Provider Practice Location Address
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Address Line | 3917 N ASHLAND AVE
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City | CHICAGO
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State | IL
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Zip | 60613-5233
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Country | US
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Telephone | 773-687-8052
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Fax |
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Provider Business Mailing Address
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Address Line | 3917 N ASHLAND AVE
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City | CHICAGO
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State | IL
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Zip | 60613-5233
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | JACKIE JONES
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Credential |
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Telephone | 773-687-8052
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 019-029332
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 019-030017
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 019-026174
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License Number State | IL
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