=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528216538
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RAVENSWOOD DENTAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/03/2008
-----------------------------------------------------
Last Update Date | 09/03/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5015 N PAULINA ST SUITE 330
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60640-2756
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-334-3555
-----------------------------------------------------
Fax | 773-334-5771
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5015 N PAULINA ST SUITE 330
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60640-2756
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-334-3555
-----------------------------------------------------
Fax | 773-334-5771
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. HENRY LOTSOF
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 773-334-3555
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 019019228
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------