Provider Demographics
NPI:1235680109
Name:CHICAGO DENTAL COSMETICS
Entity Type:Organization
Organization Name:CHICAGO DENTAL COSMETICS
Other - Org Name:ADVANCED FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MUSTAPHA
Authorized Official - Middle Name:
Authorized Official - Last Name:HOTAIT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-767-1554
Mailing Address - Street 1:6338 S PULASKI RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60629-4706
Mailing Address - Country:US
Mailing Address - Phone:773-767-1554
Mailing Address - Fax:
Practice Address - Street 1:6338 S PULASKI RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-4706
Practice Address - Country:US
Practice Address - Phone:773-767-1554
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHICAGO DENTAL COSMETICS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-17
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190281051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty