Provider Demographics
NPI:1730273558
Name:PETRIE STORER & ASSOCIATES DDS PC
Entity type:Organization
Organization Name:PETRIE STORER & ASSOCIATES DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:M
Authorized Official - Last Name:STORER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-763-5353
Mailing Address - Street 1:7447 W TALCOTT AVE
Mailing Address - Street 2:SUITE 560
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60631-3745
Mailing Address - Country:US
Mailing Address - Phone:773-763-5353
Mailing Address - Fax:773-763-3565
Practice Address - Street 1:7447 W TALCOTT AVE
Practice Address - Street 2:SUITE 560
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60631-3745
Practice Address - Country:US
Practice Address - Phone:773-763-5353
Practice Address - Fax:773-763-3565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0600067171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty