Provider Demographics
NPI:1609134378
Name:NW DENTIQ CENTER P.C
Entity Type:Organization
Organization Name:NW DENTIQ CENTER P.C
Other - Org Name:ROUND LAKE FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KALPIT
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-740-0217
Mailing Address - Street 1:425 N.WILSON ROAD
Mailing Address - Street 2:
Mailing Address - City:ROUND LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60073
Mailing Address - Country:US
Mailing Address - Phone:847-740-0217
Mailing Address - Fax:
Practice Address - Street 1:425 N.WILSON ROAD
Practice Address - Street 2:
Practice Address - City:ROUND LAKE
Practice Address - State:IL
Practice Address - Zip Code:60073
Practice Address - Country:US
Practice Address - Phone:847-740-0217
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-01
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190284071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty