NPIMap

Organization Active NPI

Chicago Mall Dental, LLC

Doing business as North Riverside Park Mall Dental

  • Dentist
  • North Riverside, IL
National Provider Identifier
1235507583
Registry record updated Sep 3, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
DentistTaxonomy code 122300000X
License
019.028976 Issued in IL
Legal business name
CHICAGO MALL DENTAL, LLC
Doing business as
North Riverside Park Mall Dental
Practice address
7501 W Cermak Rd
North Riverside, IL 60546-1438
Phone
(917) 902-9515
NPI assigned
Sep 3, 2015
Last updated
Sep 3, 2015By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 3, 2015

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Rostislav Krasnov, DDS
Title
President
Phone
(917) 902-9515

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Dentist 122300000X 019.028976 IL Primary

Addresses

Primary practice location

7501 W Cermak Rd
North Riverside, IL 60546-1438

Mailing address

7501 W Cermak Rd
North Riverside, IL 60546-1438

Other names 1

  • North Riverside Park Mall Dental Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Chicago Mall Dental LLC2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Locations

7501 W Cermak Rd
North Riverside, IL 60546
Phone (917) 902-9515

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1441238400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1441238400000",
    "number": "1235507583",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "7501 W CERMAK RD",
            "city": "NORTH RIVERSIDE",
            "state": "IL",
            "postal_code": "605461438"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "7501 W CERMAK RD",
            "city": "NORTH RIVERSIDE",
            "state": "IL",
            "postal_code": "605461438",
            "telephone_number": "917-902-9515"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CHICAGO MALL DENTAL, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-09-03",
        "last_updated": "2015-09-03",
        "status": "A",
        "authorized_official_last_name": "KRASNOV",
        "authorized_official_first_name": "ROSTISLAV",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "917-902-9515",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DDS"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "IL",
            "license": "019.028976",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "North Riverside Park Mall Dental",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in North Riverside, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 3, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.