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General NPI Number Information
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NPI Number | 1972755320
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Entity Type | Organization
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Legal Business Name | UIC COLLEGE OF DENTISTRY ORAL PATHOLOGY BIOPSY SERVICE
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Dates
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Enumeration Date | 10/16/2008
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Last Update Date | 10/16/2008
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Provider Practice Location Address
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Address Line | 801 S PAULINA ST ROOM 525A (M/C 838)
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City | CHICAGO
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State | IL
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Zip | 60612-7210
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Country | US
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Telephone | 312-996-3633
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Fax | 312-996-9226
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Provider Business Mailing Address
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Address Line | 801 S PAULINA ST ROOM 525A (M/C 838)
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City | CHICAGO
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State | IL
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Zip | 60612-7210
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Country | US
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Telephone | 312-996-3633
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Fax | 312-996-9226
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Authorized Official
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Title or Position | DIRECTOR
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Name | SARA C GORDON
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Credential | DDS MSC FRCDC
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Telephone | 312-996-1104
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number | 14D0646690
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License Number State | IL
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