Organization
IDENTITY ORTHODONTICS
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MICHAEL STOSICH (OWNER)
(847) 548-4200
Entity
Organization
Contact information
Practice address
1275 E BELVIDERE RD STE 100, GRAYSLAKE, IL 60030-2080
(847) 548-4200
Mailing address
1275 E BELVIDERE RD, GRAYSLAKE, IL 60030-2082
Taxonomy
Speciality
Code
Description
License number
State
1223X0400X
Orthodontics and Dentofacial Orthopedics Dentistry
Primary
—
—
Other
Enumeration date
12/16/2014
Last updated
12/16/2014
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