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General NPI Number Information
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NPI Number | 1790752038
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Entity Type | Organization
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Legal Business Name | LAWN DENTAL CENTER
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Dates
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Enumeration Date | 03/07/2006
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Last Update Date | 05/05/2008
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Provider Practice Location Address
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Address Line | 3113 SOUTH PULASKI
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City | CHICAGO
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State | IL
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Zip | 60623
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Country | US
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Telephone | 773-523-0700
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Fax | 773-523-0702
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Provider Business Mailing Address
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Address Line | 3113 SOUTH PULASKI
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City | CHICAGO
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State | IL
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Zip | 60623
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Country | US
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Telephone | 773-523-0700
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Fax | 773-523-0702
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Authorized Official
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Title or Position | CO OWNER DENTIST
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Name | CHARLES OLONO
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Credential | DDS
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Telephone | 773-523-0700
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019019895
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License Number State | IL
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