Provider Demographics
NPI:1215210349
Name:FAMILIA DENTAL ESL 2 LLC
Entity Type:Organization
Organization Name:FAMILIA DENTAL ESL 2 LLC
Other - Org Name:FAMILIA DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KOUSHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:H 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 1:2608 STATE ST
Practice Address - Street 2:
Practice Address - City:E SAINT LOUIS
Practice Address - State:IL
Practice Address - Zip Code:62205-2325
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:2011-09-26
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190269201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty