Provider Demographics
NPI:1538330758
Name:FAMILY DENTAL GROUP, INC.
Entity Type:Organization
Organization Name:FAMILY DENTAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDISON
Authorized Official - Middle Name:A
Authorized Official - Last Name:ISHAYA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-782-8900
Mailing Address - Street 1:3855 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-4640
Mailing Address - Country:US
Mailing Address - Phone:773-782-8900
Mailing Address - Fax:773-782-0577
Practice Address - Street 1:3855 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-4640
Practice Address - Country:US
Practice Address - Phone:773-782-8900
Practice Address - Fax:773-782-0577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-15
Last Update Date:2008-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL103156Medicaid