NPIMap

Organization Active NPI

Bridgeport Dental Specialists, LLC

  • Dentist
  • Chicago, IL
National Provider Identifier
1891025540
Registry record updated Dec 31, 2009
On this page

Key facts

NPPES NPI Registry
Primary specialty
DentistTaxonomy code 122300000X
License
019025818 Issued in IL
Legal business name
BRIDGEPORT DENTAL SPECIALISTS, LLC
Practice address
2959 S Wallace St
Chicago, IL 60616
Phone
(312) 326-5437
NPI assigned
Dec 31, 2009
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 31, 2009

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

Authorized official

Name
Dr. Sam Park, DDS
Title
Partner
Phone
(312) 326-5437

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
DentistGroup: 193400000X SINGLE SPECIALTY GROUP 122300000X 019025818 IL Primary

Addresses

Primary practice location

2959 S Wallace St
Chicago, IL 60616

Mailing address

2959 S Wallace St
Chicago, IL 60616

National Provider Directory

National Provider Directory
Tax ID family
Bridgeport Dental Specialists 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": "1262217600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1262217600000",
    "number": "1891025540",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2959 S WALLACE ST",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "60616"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2959 S WALLACE ST",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "60616",
            "telephone_number": "312-326-5437"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BRIDGEPORT DENTAL SPECIALISTS, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-12-31",
        "last_updated": "2009-12-31",
        "status": "A",
        "authorized_official_last_name": "PARK",
        "authorized_official_first_name": "SAM",
        "authorized_official_title_or_position": "PARTNER",
        "authorized_official_telephone_number": "312-326-5437",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DDS"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist",
            "state": "IL",
            "license": "019025818",
            "primary": true
        }
    ],
    "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 Dec 31, 2009; 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.