Basic Information
| Provider Information | |||||||||
| NPI: | 1902229875 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AL KADI JAZAIERLY | ||||||||
| FirstName: | AIEMAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2050 E ALGONQUIN RD STE 610 | ||||||||
| Address2: | |||||||||
| City: | SCHAUMBURG | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601734166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889884066 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1905 W SPRINGFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889884066 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2014 | ||||||||
| LastUpdateDate: | 03/26/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 019.029705 | IL | N | Dental Providers | Dentist | 1223X0400X | DS043141 | PA | N | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics | 1223X0400X | 021.002621 | IL | Y | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics |
No ID Information.