Provider Demographics
NPI:1205133527
Name:FOSTER AVENUE DENTAL CLINIC P.C.
Entity type:Organization
Organization Name:FOSTER AVENUE DENTAL CLINIC P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:H
Authorized Official - Last Name:TIETZER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-463-8860
Mailing Address - Street 1:3318 W FOSTER AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-4813
Mailing Address - Country:US
Mailing Address - Phone:773-463-8860
Mailing Address - Fax:773-463-9146
Practice Address - Street 1:1400 E GOLF RD
Practice Address - Street 2:SUITE 125
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016-1236
Practice Address - Country:US
Practice Address - Phone:847-827-7990
Practice Address - Fax:847-827-7852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-23
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019019206122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty