1083788194 NPI number — FAMILY DENTAL CARE OF CHICAGO PC

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 1083788194 NPI number — FAMILY DENTAL CARE OF CHICAGO PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY DENTAL CARE OF CHICAGO 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:
1083788194
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3105 ROSEWOOD PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOWNERS GROVE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60515-1286
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-964-4947
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4355 W FULLERTON 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:
60639-2057
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-489-2626
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PATEL
Authorized Official First Name:
MAHESH
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
773-489-2626

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)





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