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General NPI Number Information
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NPI Number | 1467774661
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Entity Type | Organization
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Legal Business Name | PARK RIDGE ENDODONTICS
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Dates
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Enumeration Date | 02/16/2010
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Last Update Date | 02/16/2010
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Provider Practice Location Address
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Address Line | 350 S NORTHWEST HWY SUITE 116
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City | PARK RIDGE
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State | IL
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Zip | 60068-4216
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Country | US
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Telephone | 847-823-4161
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Fax | 847-823-4163
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Provider Business Mailing Address
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Address Line | 350 S NORTHWEST HWY SUITE 116
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City | PARK RIDGE
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State | IL
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Zip | 60068-4216
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Country | US
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Telephone | 847-823-4161
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Fax | 847-823-4163
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. PATRICK I FITZGERALD
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Credential | DDS
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Telephone | 847-823-4161
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number | 060009606
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number | 060009606
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License Number State | IL
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