Provider Demographics
NPI:1083937742
Name:APOLLO DENTAL CLINIC, LLC
Entity Type:Organization
Organization Name:APOLLO DENTAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUMRANA
Authorized Official - Middle Name:S
Authorized Official - Last Name:AHMED
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:630-267-4205
Mailing Address - Street 1:6121 WASHINGTON ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-5305
Mailing Address - Country:US
Mailing Address - Phone:630-267-4205
Mailing Address - Fax:630-477-0447
Practice Address - Street 1:6121 WASHINGTON ST
Practice Address - Street 2:SUITE 203
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-5305
Practice Address - Country:US
Practice Address - Phone:630-267-4205
Practice Address - Fax:630-477-0447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-10
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019026293122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1005798Medicaid