Organization
CHICAGO MALL DENTAL, LLC
Active
Other names
North Riverside Park Mall Dental
Organization subpart
No
Provider details
NPI number
Authorized official
DR. ROSTISLAV KRASNOV DDS (PRESIDENT)
(917) 902-9515
Entity
Organization
Contact information
Practice address
7501 W CERMAK RD, NORTH RIVERSIDE, IL 60546-1438
(917) 902-9515
Mailing address
7501 W CERMAK RD, NORTH RIVERSIDE, IL 60546-1438
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
019.028976
IL
Other
Enumeration date
09/03/2015
Last updated
09/03/2015
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