Provider Demographics
NPI:1144587882
Name:FAMILIA DENTAL WHEELING 3 LLC
Entity Type:Organization
Organization Name:FAMILIA DENTAL WHEELING 3 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KOUSHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:AZAD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:888-988-4066
Mailing Address - Street 1:2050 E ALGONQUIN RD
Mailing Address - Street 2:SUITE 610
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60173-4144
Mailing Address - Country:US
Mailing Address - Phone:888-988-4066
Mailing Address - Fax:847-496-7202
Practice Address - Street 1:542 W DUNDEE RD
Practice Address - Street 2:SUITE B
Practice Address - City:WHEELING
Practice Address - State:IL
Practice Address - Zip Code:60090-3227
Practice Address - Country:US
Practice Address - Phone:888-988-4066
Practice Address - Fax:847-496-7202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-19
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty