Provider Demographics
NPI:1366599748
Name:CHICAGO ORAL & MAXILLOFACIAL SURGERY
Entity type:Organization
Organization Name:CHICAGO ORAL & MAXILLOFACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NEIL
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:HAGEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:312-926-2929
Mailing Address - Street 1:676 N ST. CLAIR STREET
Mailing Address - Street 2:SUITE 2280
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3197
Mailing Address - Country:US
Mailing Address - Phone:312-926-2929
Mailing Address - Fax:312-926-3595
Practice Address - Street 1:676 N ST. CLAIR STREET
Practice Address - Street 2:SUITE 2280
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3197
Practice Address - Country:US
Practice Address - Phone:312-926-2929
Practice Address - Fax:312-926-3595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL21-0010741223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty