=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912136623
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MONTROSE DENTAL CLINIC PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2009
-----------------------------------------------------
Last Update Date | 07/02/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3541 W. MONTROSE AVE UNIT 1W
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-463-8000
-----------------------------------------------------
Fax | 773-463-8001
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3541 W. MONTROSE AVE UNIT 1W
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-463-8000
-----------------------------------------------------
Fax | 773-463-8001
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DAVID FANG
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 773-969-0198
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 019025991
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------