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General NPI Number Information
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NPI Number | 1710226386
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Entity Type | Organization
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Legal Business Name | LINCOLN COSMETIC DENTISTRY LLC
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Dates
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Enumeration Date | 02/02/2013
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Last Update Date | 02/02/2013
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Provider Practice Location Address
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Address Line | 5962 N LINCOLN AVE STE 10
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City | CHICAGO
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State | IL
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Zip | 60659-3762
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Country | US
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Telephone | 773-878-3168
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Fax | 773-878-3317
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Provider Business Mailing Address
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Address Line | 5962 N LINCOLN AVE STE 10
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City | CHICAGO
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State | IL
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Zip | 60659-3762
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Country | US
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Telephone | 773-878-3168
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Fax | 773-878-3317
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Authorized Official
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Title or Position | OWNER
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Name | KATHERINE GERGINIS
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Credential |
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Telephone | 773-878-3168
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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 | 019016806
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License Number State | IL
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