NPIMap

Organization Active NPI

Modern Dental on Clark Street

  • General Practice Dentistry
  • Chicago, IL
National Provider Identifier
1265962674
Registry record updated Jun 18, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Practice DentistryTaxonomy code 1223G0001X
Legal business name
MODERN DENTAL ON CLARK STREET
Practice address
744 N Clark St
Chicago, IL 60654-2525
Phone
(773) 489-5700
NPI assigned
Jun 18, 2017
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 18, 2017

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

Authorized official

Name
Dr. Phillip Palella, DDSNPI 1063488609
Title
Owner
Phone
(773) 489-5700

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
General Practice DentistryGroup: 193400000X SINGLE SPECIALTY GROUP 1223G0001X Primary
Dental Clinic/Center 261QD0000X
Preferred Provider Organization 305R00000X

Addresses

Primary practice location

744 N Clark St
Chicago, IL 60654-2525

Mailing address

2037 W Division St
Chicago, IL 60622-3157

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1497744000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1497744000000",
    "number": "1265962674",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2037 W DIVISION ST",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606223157"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "744 N CLARK ST",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606542525",
            "telephone_number": "773-489-5700"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MODERN DENTAL ON CLARK STREET",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-06-18",
        "last_updated": "2017-06-18",
        "status": "A",
        "authorized_official_last_name": "PALELLA",
        "authorized_official_first_name": "PHILLIP",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "773-489-5700",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DDS"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, General Practice",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "261QD0000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Dental",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "305R00000X",
            "taxonomy_group": "",
            "desc": "Preferred Provider Organization",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Chicago, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 18, 2017; 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.