Provider Demographics
NPI:1447767546
Name:CICERO DENTAL CENTER LLC
Entity Type:Organization
Organization Name:CICERO DENTAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:HAMZA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOHAMMED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-437-0774
Mailing Address - Street 1:1639 S CICERO AVE
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:IL
Mailing Address - Zip Code:60804-1520
Mailing Address - Country:US
Mailing Address - Phone:708-477-6717
Mailing Address - Fax:708-477-6434
Practice Address - Street 1:1639 S CICERO AVE
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:IL
Practice Address - Zip Code:60804-1520
Practice Address - Country:US
Practice Address - Phone:708-477-6717
Practice Address - Fax:708-477-6434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-10
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL17109779391223G0001X
IL11848261741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty