Provider Demographics
NPI:1275874182
Name:PERIODONTICS & DENTAL IMPLANT CENTER LTD
Entity Type:Organization
Organization Name:PERIODONTICS & DENTAL IMPLANT CENTER LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AMJOD
Authorized Official - Middle Name:
Authorized Official - Last Name:ALDOLLAL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-847-9004
Mailing Address - Street 1:1900 W 47TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60609-3833
Mailing Address - Country:US
Mailing Address - Phone:773-847-9004
Mailing Address - Fax:773-847-9008
Practice Address - Street 1:1900 W 47TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60609-3833
Practice Address - Country:US
Practice Address - Phone:773-847-9004
Practice Address - Fax:773-847-9008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-04
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190285311223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019028531Medicaid