Basic Information
| Provider Information | |||||||||
| NPI: | 1013283126 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILIA DENTAL ESL 4LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2050 E ALGONQUIN RD | ||||||||
| Address2: | 610 | ||||||||
| City: | SCHAUMBURG | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601734144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889884066 | ||||||||
| FaxNumber: | 8474967202 | ||||||||
| Practice Location | |||||||||
| Address1: | 2608 STATE ST | ||||||||
| Address2: | |||||||||
| City: | EAST SAINT LOUIS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622052325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889884066 | ||||||||
| FaxNumber: | 8474967202 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2012 | ||||||||
| LastUpdateDate: | 03/23/2012 | ||||||||
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| AuthorizedOfficialLastName: | AZAD | ||||||||
| AuthorizedOfficialFirstName: | KOUSHAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8889884066 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DMD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 019026920 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.