Provider Demographics
NPI:1639239478
Name:PERLA DENTAL 26TH STREET LLC
Entity Type:Organization
Organization Name:PERLA DENTAL 26TH STREET LLC
Other - Org Name:PERLA DENTAL
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:VICKEN
Authorized Official - Middle Name:
Authorized Official - Last Name:ICHKHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-521-1190
Mailing Address - Street 1:3948 W 26TH ST
Mailing Address - Street 2:STE 101
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60623-3738
Mailing Address - Country:US
Mailing Address - Phone:773-521-1190
Mailing Address - Fax:773-521-1147
Practice Address - Street 1:3948 W 26TH ST
Practice Address - Street 2:STE 101
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-3738
Practice Address - Country:US
Practice Address - Phone:773-521-1190
Practice Address - Fax:773-521-1147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty