Provider Demographics
NPI:1548484793
Name:UNIVERSITY DENTAL PROFESSIONALS
Entity type:Organization
Organization Name:UNIVERSITY DENTAL PROFESSIONALS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:RECKAMP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-684-5702
Mailing Address - Street 1:5549 S CORNELL AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60637-1914
Mailing Address - Country:US
Mailing Address - Phone:773-684-5702
Mailing Address - Fax:773-684-5493
Practice Address - Street 1:5549 S CORNELL AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-1914
Practice Address - Country:US
Practice Address - Phone:773-684-5702
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019026856122300000X
IL019024994122300000X
IL019026908122300000X
IL019018517122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty