Provider Demographics
NPI:1407253339
Name:MILWAUKEE DENTAL CLINIC, INC
Entity Type:Organization
Organization Name:MILWAUKEE DENTAL CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:IMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:BAHRANI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-282-7906
Mailing Address - Street 1:4254 N MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-1643
Mailing Address - Country:US
Mailing Address - Phone:773-282-7906
Mailing Address - Fax:773-427-2740
Practice Address - Street 1:4254 N MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-1643
Practice Address - Country:US
Practice Address - Phone:773-282-7906
Practice Address - Fax:773-427-2740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-20
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190175111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty