Provider Demographics
NPI:1619212131
Name:CHICAGO DENTAL COSMETICS
Entity Type:Organization
Organization Name:CHICAGO DENTAL COSMETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MUSTAPHA
Authorized Official - Middle Name:A
Authorized Official - Last Name:HOTAIT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:708-849-4644
Mailing Address - Street 1:6338 S PULASKI RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60629-4706
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6338 S PULASKI RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-4706
Practice Address - Country:US
Practice Address - Phone:708-849-4644
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-10
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019028105261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental