Provider Demographics
NPI:1376325985
Name:SECURE DENTAL XII LLC
Entity Type:Organization
Organization Name:SECURE DENTAL XII LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:NAZISH
Authorized Official - Middle Name:
Authorized Official - Last Name:JAFRI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:815-708-2762
Mailing Address - Street 1:502 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:EAST PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61611-2068
Mailing Address - Country:US
Mailing Address - Phone:309-606-5008
Mailing Address - Fax:
Practice Address - Street 1:820 N THOMPSON LN STE 8361A-B
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37129-4339
Practice Address - Country:US
Practice Address - Phone:309-606-5008
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-18
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental