Provider Demographics
NPI:1073155750
Name:GRAYSLAKE DENTAL CRARE
Entity Type:Organization
Organization Name:GRAYSLAKE DENTAL CRARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FATEMEH
Authorized Official - Middle Name:
Authorized Official - Last Name:AFSHAR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-223-2023
Mailing Address - Street 1:997 N CORPORATE CIR STE A
Mailing Address - Street 2:
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-7822
Mailing Address - Country:US
Mailing Address - Phone:847-223-2023
Mailing Address - Fax:847-223-2012
Practice Address - Street 1:997 N CORPORATE CIR STE A
Practice Address - Street 2:
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-7822
Practice Address - Country:US
Practice Address - Phone:847-223-2023
Practice Address - Fax:847-223-2012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-14
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental