Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | 021-001495 | IL |
NPI | 1013134154 |
---|---|
Provider Name | Dr. Jerry Udelson |
First Address | Forest Park, IL 60130-2381 |
Second Address | Forest Park, IL 60130-2337 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/04/2007 |
Last Update Date | 07/08/2020 |