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General NPI Number Information
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NPI Number | 1922527852
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Entity Type | Organization
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Legal Business Name | STONY ISLAND DENTALWORKS LLC
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Dates
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Enumeration Date | 09/12/2017
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Last Update Date | 11/18/2019
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Provider Practice Location Address
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Address Line | 2235 E 71ST ST
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City | CHICAGO
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State | IL
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Zip | 60649-2539
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Country | US
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Telephone | 773-493-4937
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Fax | 773-675-4419
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Provider Business Mailing Address
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Address Line | 56 E 47TH ST STE 200
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City | CHICAGO
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State | IL
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Zip | 60653-3982
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Country | US
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Telephone | 773-858-7481
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Fax | 773-675-4419
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | DR. REGINALD TORRANCE BAKER
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Credential | DDS
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Telephone | 773-493-4937
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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 | 19-025166
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License Number State | IL
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