Basic Information
| Provider Information | |||||||||
| NPI: | 1568725943 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DECATUR 2013 LLC | ||||||||
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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: | 8474967603 | ||||||||
| Practice Location | |||||||||
| Address1: | 141 E PERSHING RD | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625263213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889884066 | ||||||||
| FaxNumber: | 8474967603 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2012 | ||||||||
| LastUpdateDate: | 06/20/2012 | ||||||||
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| AuthorizedOfficialLastName: | AZAD | ||||||||
| AuthorizedOfficialFirstName: | KOUSHAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER /PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8889884066 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DMD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.