Provider Demographics
NPI:1558659169
Name:PRISTINE FAMILY DENTAL
Entity Type:Organization
Organization Name:PRISTINE FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANJUM
Authorized Official - Middle Name:ZAHEER
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-816-2595
Mailing Address - Street 1:384 S WEBER RD
Mailing Address - Street 2:
Mailing Address - City:ROMEOVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60446-6521
Mailing Address - Country:US
Mailing Address - Phone:815-609-1600
Mailing Address - Fax:
Practice Address - Street 1:384 S WEBER RD
Practice Address - Street 2:
Practice Address - City:ROMEOVILLE
Practice Address - State:IL
Practice Address - Zip Code:60446-6521
Practice Address - Country:US
Practice Address - Phone:815-609-1600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-17
Last Update Date:2011-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190269521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty