Provider Demographics
NPI:1326038738
Name:WEST TOWN DENTAL GROUP
Entity Type:Organization
Organization Name:WEST TOWN DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SABAH
Authorized Official - Middle Name:H
Authorized Official - Last Name:KHALIFA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-252-5772
Mailing Address - Street 1:1229 N ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-2204
Mailing Address - Country:US
Mailing Address - Phone:773-252-5772
Mailing Address - Fax:773-278-0543
Practice Address - Street 1:1229 N ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-2204
Practice Address - Country:US
Practice Address - Phone:773-252-5772
Practice Address - Fax:773-278-0543
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL01915779122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty