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General NPI Number Information
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NPI Number | 1629143649
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Entity Type | Organization
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Legal Business Name | THE CHICAGO CENTER FOR COSMETIC AND IMPLANT DENTIS
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Dates
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Enumeration Date | 11/22/2006
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Last Update Date | 07/10/2007
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Provider Practice Location Address
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Address Line | 205 W MAIN STREET
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City | BARRINGTON
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State | IL
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Zip | 60010-3222
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Country | US
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Telephone | 847-842-6900
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Fax | 847-842-6966
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Provider Business Mailing Address
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Address Line | 205 W MAIN STREET
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City | BARRINGTON
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State | IL
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Zip | 60010-3222
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Country | US
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Telephone | 847-842-6900
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Fax | 847-842-6966
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. THOMAS FRANCIS JACKSON
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Credential | DDS
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Telephone | 847-842-6900
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number |
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License Number State | IL
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