Provider Demographics
NPI:1548580780
Name:FAMILIA DENTAL PEORIA 4 LLC
Entity Type:Organization
Organization Name:FAMILIA DENTAL PEORIA 4 LLC
Other - Org Name:FAMILIA DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KOUSHAN
Authorized Official - Middle Name:H
Authorized Official - Last Name:AZAD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:888-988-4066
Mailing Address - Street 1:2000 E ALGONQUIN ROAD SUITE 109
Mailing Address - Street 2:
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60173-4189
Mailing Address - Country:US
Mailing Address - Phone:888-988-4066
Mailing Address - Fax:847-496-7603
Practice Address - Street 1:1403 W. GLEN
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614
Practice Address - Country:US
Practice Address - Phone:888-988-4066
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-10
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty