1568917508 NPI number — DENTAL SHINE II P.C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568917508 NPI number — DENTAL SHINE II P.C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DENTAL SHINE II P.C
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:
6
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:
1568917508
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/19/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11830 S ROUTE 59
Provider Second Line Business Mailing Address:
SUITE 110
Provider Business Mailing Address City Name:
PLAINFIELD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60585-5894
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-609-0000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11830 S ROUTE 59
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
PLAINFIELD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60585-5894
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-609-0000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/19/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
EL-MUQDAD
Authorized Official First Name:
FIRAS
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
708-769-1073

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  019026154 , 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)