Basic Information
| Provider Information | |||||||||
| NPI: | 1104109230 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAMILIA DENTAL SPRINGFIELD 2 LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | FAMILIA DENTAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2050 E ALGONQUIN RD | ||||||||
| Address2: | SUITE 610 | ||||||||
| City: | SCHAUMBURG | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601734144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889884066 | ||||||||
| FaxNumber: | 8474967202 | ||||||||
| Practice Location | |||||||||
| Address1: | 802 N 9TH ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627026309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889884066 | ||||||||
| FaxNumber: | 8474967202 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2011 | ||||||||
| LastUpdateDate: | 09/26/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | H AZAD | ||||||||
| AuthorizedOfficialFirstName: | KOUSHAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8889884066 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DMD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 019026920 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist |
No ID Information.