Provider Demographics
NPI:1649773144
Name:DENTUM DENTAL LTD
Entity Type:Organization
Organization Name:DENTUM DENTAL LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:FAIZAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-949-9000
Mailing Address - Street 1:319 N WEBER RD # 397
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60490-1569
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5500 S DAMEN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60636-1107
Practice Address - Country:US
Practice Address - Phone:312-949-9000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-12
Last Update Date:2018-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019020204122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019020204Medicaid