=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760539324
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SRB DENTAL PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2007
-----------------------------------------------------
Last Update Date | 06/21/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 850 S WABASH AVE SUITE 250
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60605-3641
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-663-1890
-----------------------------------------------------
Fax | 312-663-1895
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 6776
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60680-6776
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-663-1890
-----------------------------------------------------
Fax | 312-663-1895
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT DOCTOR
-----------------------------------------------------
Name | DR. SHEILA RENEE' BROWN
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 312-663-1890
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 019019737
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------