Organization
FOSTER AVENUE DENTAL CLINIC P.C.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. GREGORY H TIETZER D.D.S. (OWNER)
(773) 463-8860
Entity
Organization
Contact information
Practice address
1400 E GOLF RD, SUITE 125, DES PLAINES, IL 60016-1236
(847) 827-7990
(847) 827-7852
Mailing address
3318 W FOSTER AVE, CHICAGO, IL 60625-4813
(773) 463-8860
(773) 463-9146
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
019019206
IL
Other
Enumeration date
02/23/2011
Last updated
02/23/2011
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