Provider Demographics
NPI:1235400821
Name:THE DENTAL LOFT, LLC
Entity Type:Organization
Organization Name:THE DENTAL LOFT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ELHAM
Authorized Official - Middle Name:
Authorized Official - Last Name:SHARAF-ELDEEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:708-482-0702
Mailing Address - Street 1:1 W HARRIS AVE
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-2496
Mailing Address - Country:US
Mailing Address - Phone:708-482-0702
Mailing Address - Fax:
Practice Address - Street 1:1 W HARRIS AVE
Practice Address - Street 2:SECOND FLOOR, SUITE A
Practice Address - City:LA GRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-2496
Practice Address - Country:US
Practice Address - Phone:708-482-0702
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-13
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.028065122300000X
IL019.027663122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty