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General NPI Number Information
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NPI Number | 1730467796
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Entity Type | Organization
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Legal Business Name | CHATHAM DENTALWORKS PC
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Dates
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Enumeration Date | 07/25/2011
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Last Update Date | 07/25/2011
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Provider Practice Location Address
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Address Line | 8803 S STONY ISLAND AVE
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City | CHICAGO
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State | IL
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Zip | 60617-2810
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Country | US
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Telephone | 773-375-0303
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Fax | 773-375-9018
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Provider Business Mailing Address
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Address Line | 8803 S STONY ISLAND AVE
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City | CHICAGO
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State | IL
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Zip | 60617-2810
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Country | US
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Telephone | 773-375-0303
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Fax | 773-375-9018
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Authorized Official
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Title or Position | CEO
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Name | DR. REGINALD T BAKER
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Credential | D.D.S.
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Telephone | 773-375-0303
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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 | 019025166
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License Number State | IL
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