Provider Demographics
NPI:1255400925
Name:80TH AVE DENTAL ASSOCIATES
Entity type:Organization
Organization Name:80TH AVE DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:STRAUMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:708-429-3504
Mailing Address - Street 1:16717 80TH AVE
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-2361
Mailing Address - Country:US
Mailing Address - Phone:708-429-3504
Mailing Address - Fax:708-429-5667
Practice Address - Street 1:16717 80TH AVE
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-2361
Practice Address - Country:US
Practice Address - Phone:708-429-3504
Practice Address - Fax:708-429-5667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190166581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
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