=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942607924
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE ORTHO SUITE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/19/2014
-----------------------------------------------------
Last Update Date | 11/19/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3021 W ARMITAGE AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60647-6569
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-772-2545
-----------------------------------------------------
Fax | 773-772-2555
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3033 W ARMITAGE AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60647-3816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-772-2545
-----------------------------------------------------
Fax | 773-772-2555
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ORTHODONTIST
-----------------------------------------------------
Name | MR. ANTHONY PETER ELTINK
-----------------------------------------------------
Credential | D.M.D, M.S
-----------------------------------------------------
Telephone | 773-772-2545
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 019-026027
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------