NPIMap

Organization Active NPI

Chicago Mall Dental, LLC

  • Dentist
  • Lincolnwood, IL
National Provider Identifier
1801263090
Registry record updated Aug 24, 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
Practice address
3333 W Touhy Ave
Lincolnwood, IL 60712-2721
Phone
(917) 902-9515
NPI assigned
Aug 24, 2015
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 24, 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
(786) 475-7600

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
DentistGroup: 193200000X MULTI-SPECIALTY GROUP 122300000X 019.028976 IL Primary

Addresses

Primary practice location

3333 W Touhy Ave
Lincolnwood, IL 60712-2721

Mailing address

3333 W Touhy Ave
Lincolnwood, IL 60712-2721

Other names 1

  • Lincolnwood 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.

NPI Registry JSON

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

{
    "created_epoch": "1440374400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1440374400000",
    "number": "1801263090",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3333 W TOUHY AVE",
            "city": "LINCOLNWOOD",
            "state": "IL",
            "postal_code": "607122721"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3333 W TOUHY AVE",
            "city": "LINCOLNWOOD",
            "state": "IL",
            "postal_code": "607122721",
            "telephone_number": "917-902-9515"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CHICAGO MALL DENTAL, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-08-24",
        "last_updated": "2015-08-24",
        "status": "A",
        "authorized_official_last_name": "KRASNOV",
        "authorized_official_first_name": "ROSTISLAV",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "786-475-7600",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DDS"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist",
            "state": "IL",
            "license": "019.028976",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Lincolnwood Mall Dental",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Lincolnwood, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 24, 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.