Provider Demographics
NPI:1093954091
Name:EUCLID ADVANCED DENTISTRY, P.C
Entity Type:Organization
Organization Name:EUCLID ADVANCED DENTISTRY, P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SABA
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-368-0200
Mailing Address - Street 1:409 E EUCLID AVE STE B
Mailing Address - Street 2:
Mailing Address - City:MOUNT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-1214
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:409 E EUCLID AVE STE B
Practice Address - Street 2:
Practice Address - City:MOUNT PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056-1214
Practice Address - Country:US
Practice Address - Phone:847-368-0200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-13
Last Update Date:2009-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019027311122300000X
IL0210022161223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL195558Medicaid