Provider Demographics
NPI:1003449018
Name:DOVER DENTAL CENTER
Entity Type:Organization
Organization Name:DOVER DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARYAM
Authorized Official - Middle Name:
Authorized Official - Last Name:HAFEZI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:630-851-7878
Mailing Address - Street 1:95 TRADE ST STE 101
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-8296
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:95 TRADE ST STE 101
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-8296
Practice Address - Country:US
Practice Address - Phone:630-851-7878
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-18
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019025427Medicaid