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General NPI Number Information
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NPI Number | 1821263740
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Entity Type | Organization
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Legal Business Name | ARTESIAN DENTAL
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Dates
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Enumeration Date | 04/23/2008
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Last Update Date | 04/23/2008
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Provider Practice Location Address
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Address Line | 227 E. 47TH STREET
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City | CHICAGO
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State | IL
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Zip | 60653
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Country | US
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Telephone | 773-536-1434
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Fax | 773-536-1378
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Provider Business Mailing Address
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Address Line | 227 E 47TH ST
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City | CHICAGO
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State | IL
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Zip | 60653-3903
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Country | US
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Telephone | 773-536-1434
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Fax | 773-536-1378
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Authorized Official
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Title or Position | DENTIST
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Name | DR. HORACE C. BROY JR.
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Credential | DR.
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Telephone | 773-536-1434
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 019022596
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License Number State | IL
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