1518246735 NPI number — INTERNATIONAL DENTAL CENTER

Table of content: DR. STEPHANIE NICOLE PETIT PHARMD (NPI 1730530841)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518246735 NPI number — INTERNATIONAL DENTAL CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTERNATIONAL DENTAL CENTER
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:
1518246735
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
305 W INDIAN TRL
Provider Second Line Business Mailing Address:
UNIT C
Provider Business Mailing Address City Name:
AURORA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60506-2400
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-859-8660
Provider Business Mailing Address Fax Number:
630-859-8666

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
305 W INDIAN TRL
Provider Second Line Business Practice Location Address:
UNIT C
Provider Business Practice Location Address City Name:
AURORA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60506-2400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-859-8660
Provider Business Practice Location Address Fax Number:
630-859-8666
Provider Enumeration Date:
08/04/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MOHAMMAD
Authorized Official First Name:
RABEH
Authorized Official Middle Name:
SALAMAH
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
773-865-2859

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , 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)