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General NPI Number Information
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NPI Number | 1629218557
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Entity Type | Organization
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Legal Business Name | CITY KIDS DENTAL NORTH SHORE, LLC
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Dates
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Enumeration Date | 03/05/2009
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Last Update Date | 08/16/2012
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Provider Practice Location Address
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Address Line | 585 LINCOLN AVE SUITE 2
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City | WINNETKA
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State | IL
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Zip | 60093-2351
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Country | US
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Telephone | 847-446-0950
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Fax | 847-446-0985
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Provider Business Mailing Address
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Address Line | 585 LINCOLN AVE SUITE 2
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City | WINNETKA
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State | IL
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Zip | 60093-2351
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Country | US
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Telephone | 847-446-0950
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Fax | 847-446-0985
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Authorized Official
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Title or Position | CO-OWNER
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Name | DR. A. MELISSA LOPEZ
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Credential | DMD, MPH
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Telephone | 847-446-0950
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 019025964
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License Number State | IL
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