=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649496514
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PINE DENTAL CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2536 N LINCOLN AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60614-2889
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-880-5455
-----------------------------------------------------
Fax | 773-880-5809
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2536 N LINCOLN AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60614-2889
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-880-5455
-----------------------------------------------------
Fax | 773-880-5809
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. CHARLES STANLEY CZEREPAK
-----------------------------------------------------
Credential | D.M.D.
-----------------------------------------------------
Telephone | 773-880-5455
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------