=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770742389
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RONALD C. HARTZER D.D.S.,M.S., PERIODONTICS, LTD.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2008
-----------------------------------------------------
Last Update Date | 06/09/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 609 W GREENWOOD AVE
-----------------------------------------------------
City | WAUKEGAN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60087-5000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-244-9000
-----------------------------------------------------
Fax | 847-244-0009
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 609 W GREENWOOD AVE
-----------------------------------------------------
City | WAUKEGAN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60087-5000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-244-9000
-----------------------------------------------------
Fax | 847-244-0009
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. RONALD C. HARTZER
-----------------------------------------------------
Credential | D.D.S., M.S.
-----------------------------------------------------
Telephone | 847-244-9000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 019013133
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------