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General NPI Number Information
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NPI Number | 1578246930
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Entity Type | Organization
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Legal Business Name | BRISTLE DENTAL STUDIO
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Dates
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Enumeration Date | 08/10/2023
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Last Update Date | 01/05/2024
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Provider Practice Location Address
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Address Line | 1700 N WESTERN AVE UNIT A
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City | CHICAGO
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State | IL
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Zip | 60647-5324
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Country | US
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Telephone | 312-620-7733
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Fax |
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Provider Business Mailing Address
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Address Line | 1700 N WESTERN AVE UNIT A
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City | CHICAGO
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State | IL
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Zip | 60647-5324
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Country | US
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Telephone | 312-620-7733
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | CONNIE J WOO
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Credential | DMD
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Telephone | 224-612-1383
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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 |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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