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General NPI Number Information
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NPI Number | 1790146132
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Entity Type | Organization
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Legal Business Name | FAMILY MILLENNIUM DENTISTRY, INC.
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Dates
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Enumeration Date | 03/13/2016
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Last Update Date | 04/08/2016
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Provider Practice Location Address
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Address Line | 1342 W RANDOLPH ST
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City | CHICAGO
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State | IL
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Zip | 60607-1522
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Country | US
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Telephone | 312-767-0407
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Fax | 312-988-0292
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Provider Business Mailing Address
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Address Line | 1342 W RANDOLPH ST
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City | CHICAGO
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State | IL
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Zip | 60607-1522
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Country | US
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Telephone | 312-767-0407
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Fax | 312-988-0292
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Authorized Official
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Title or Position | DENTIST / OWNER
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Name | LAWRENCE H ZAGER
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Credential | D.D.S. PC
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Telephone | 312-767-0407
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 021001094
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License Number State | IL
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