Provider Demographics
NPI:1609895754
Name:ADVANCE DENTAL MAKEOVER PC
Entity Type:Organization
Organization Name:ADVANCE DENTAL MAKEOVER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WISAM
Authorized Official - Middle Name:R
Authorized Official - Last Name:MOHAMMAD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-604-5050
Mailing Address - Street 1:4707 N PULASKI RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-4312
Mailing Address - Country:US
Mailing Address - Phone:773-604-5050
Mailing Address - Fax:773-604-5030
Practice Address - Street 1:4707 N PULASKI RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-4312
Practice Address - Country:US
Practice Address - Phone:773-604-5050
Practice Address - Fax:773-604-5030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty