=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518610617
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VON WESTERNHAGEN DENTAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/28/2022
-----------------------------------------------------
Last Update Date | 11/01/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4160 E HIGHLAND AVE STE J
-----------------------------------------------------
City | HIGHLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92346-2750
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-274-4546
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 350 N CLARK ST STE 600
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60654-4782
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-274-4581
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING
-----------------------------------------------------
Name | PETER STATHAKIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 312-274-4546
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------