Provider Demographics
NPI:1366195869
Name:PARK RIDGE DENTISTRY PLLC
Entity type:Organization
Organization Name:PARK RIDGE DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE COORDINATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:STITES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-610-2903
Mailing Address - Street 1:1699 E WOODFIELD RD STE 102
Mailing Address - Street 2:
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60173-4955
Mailing Address - Country:US
Mailing Address - Phone:630-869-5857
Mailing Address - Fax:
Practice Address - Street 1:35 1/2 S PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-4101
Practice Address - Country:US
Practice Address - Phone:847-692-7350
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-03
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty