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General NPI Number Information
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NPI Number | 1679014062
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Entity Type | Organization
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Legal Business Name | SAM MUDRIK DDS LTD
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Dates
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Enumeration Date | 03/17/2017
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Last Update Date | 03/17/2017
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Provider Practice Location Address
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Address Line | 317 W DUNDEE RD
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City | BUFFALO GROVE
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State | IL
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Zip | 60089-3545
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Country | US
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Telephone | 847-520-3020
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Fax | 847-520-7564
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Provider Business Mailing Address
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Address Line | 317 W DUNDEE RD
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City | BUFFALO GROVE
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State | IL
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Zip | 60089-3545
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Country | US
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Telephone | 847-520-3020
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Fax | 847-520-7564
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Authorized Official
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Title or Position | FRONT DESK COORDINATOR
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Name | TERESA SANCHEZ
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Credential |
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Telephone | 847-520-3020
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 019.026125
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License Number State | IL
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