1205084456 NPI number — MOHAMMAD R EKHTERA, DDS.PC

Table of content: (NPI 1205084456)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205084456 NPI number — MOHAMMAD R EKHTERA, DDS.PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOHAMMAD R EKHTERA, DDS.PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205084456
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1700 WASHINGTON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILMETTE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60091-2421
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-920-0320
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4235 W ARMITAGE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60639-3646
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-342-1600
Provider Business Practice Location Address Fax Number:
773-342-1601
Provider Enumeration Date:
08/29/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
EKHTERA
Authorized Official First Name:
MOHAMMAD
Authorized Official Middle Name:
REZA
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
847-920-0320

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  31901441 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1005436 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".