Provider Demographics
NPI:1629218557
Name:CITY KIDS DENTAL NORTH SHORE, LLC
Entity type:Organization
Organization Name:CITY KIDS DENTAL NORTH SHORE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:A. MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MPH
Authorized Official - Phone:847-446-0950
Mailing Address - Street 1:585 LINCOLN AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:WINNETKA
Mailing Address - State:IL
Mailing Address - Zip Code:60093-2351
Mailing Address - Country:US
Mailing Address - Phone:847-446-0950
Mailing Address - Fax:847-446-0985
Practice Address - Street 1:585 LINCOLN AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:WINNETKA
Practice Address - State:IL
Practice Address - Zip Code:60093-2351
Practice Address - Country:US
Practice Address - Phone:847-446-0950
Practice Address - Fax:847-446-0985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-05
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190259641223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty