Provider Demographics
NPI:1184866329
Name:ADVANCED DENTISTRY AT MORTON GROVE
Entity Type:Organization
Organization Name:ADVANCED DENTISTRY AT MORTON GROVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BEHZAD
Authorized Official - Middle Name:
Authorized Official - Last Name:SANEI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:773-383-0868
Mailing Address - Street 1:5821 DEMPSTER ST
Mailing Address - Street 2:
Mailing Address - City:MORTON GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60053-3028
Mailing Address - Country:US
Mailing Address - Phone:847-581-1942
Mailing Address - Fax:847-581-1943
Practice Address - Street 1:5821 DEMPSTER ST
Practice Address - Street 2:
Practice Address - City:MORTON GROVE
Practice Address - State:IL
Practice Address - Zip Code:60053-3028
Practice Address - Country:US
Practice Address - Phone:847-581-1942
Practice Address - Fax:847-581-1943
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-02
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.027311122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL195558Medicaid