Provider Demographics
NPI:1164797197
Name:VAJDI KHOSHNOOD, GLORIA V (DDS)
Entity Type:Individual
Prefix:DR
First Name:GLORIA
Middle Name:V
Last Name:VAJDI KHOSHNOOD
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 N WABASH AVE
Mailing Address - Street 2:SUITE 2003
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-1903
Mailing Address - Country:US
Mailing Address - Phone:312-372-2945
Mailing Address - Fax:312-372-2947
Practice Address - Street 1:111 N WABASH AVE
Practice Address - Street 2:SUITE 2003
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-1903
Practice Address - Country:US
Practice Address - Phone:312-372-2945
Practice Address - Fax:312-372-2947
Is Sole Proprietor?:No
Enumeration Date:2012-03-08
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190251421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice