Provider Demographics
NPI:1447410139
Name:THE PREVENTIVE DENTISTRY CNTR PC
Entity type:Organization
Organization Name:THE PREVENTIVE DENTISTRY CNTR PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:G
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-445-3337
Mailing Address - Street 1:PO BOX 29052
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60629-0052
Mailing Address - Country:US
Mailing Address - Phone:773-445-3337
Mailing Address - Fax:773-445-3340
Practice Address - Street 1:8244 S KEDZIE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60652-3329
Practice Address - Country:US
Practice Address - Phone:773-445-3337
Practice Address - Fax:773-445-3340
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE PREVENTIVE DENTISTRY CENTER PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-16
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190233831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty