Provider Demographics
NPI: | 1275901464 |
---|---|
Name: | A TAGHIPOUR DDS PC |
Entity Type: | Organization |
Organization Name: | A TAGHIPOUR DDS PC |
Other - Org Name: | SKY DENTAL |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | DENTIST/PRACTICE OWNER |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | ALI |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | TAGHIPOUR |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DDS |
Authorized Official - Phone: | 773-840-8484 |
Mailing Address - Street 1: | 916 W BELMONT AVE # 201 |
Mailing Address - Street 2: | |
Mailing Address - City: | CHICAGO |
Mailing Address - State: | IL |
Mailing Address - Zip Code: | 60657-4427 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 773-840-8484 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 916 W BELMONT AVE # 201 |
Practice Address - Street 2: | |
Practice Address - City: | CHICAGO |
Practice Address - State: | IL |
Practice Address - Zip Code: | 60657-4427 |
Practice Address - Country: | US |
Practice Address - Phone: | 773-840-8484 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2015-09-04 |
Last Update Date: | 2015-09-04 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
IL | 019.027396 | 122300000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 122300000X | Dental Providers | Dentist | Group - Single Specialty |