Provider Demographics
NPI:1023132859
Name:ORAL & MAXILLOFACIAL SURGEONS OF LAKE COUNTY, P.C.
Entity type:Organization
Organization Name:ORAL & MAXILLOFACIAL SURGEONS OF LAKE COUNTY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FABIAN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:LATOCHA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-623-2830
Mailing Address - Street 1:202 S GREENLEAF ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-3399
Mailing Address - Country:US
Mailing Address - Phone:847-623-2830
Mailing Address - Fax:847-623-1534
Practice Address - Street 1:202 S GREENLEAF ST
Practice Address - Street 2:SUITE A
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-3399
Practice Address - Country:US
Practice Address - Phone:847-623-2830
Practice Address - Fax:847-623-1534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Single Specialty