Provider Demographics
NPI:1679852057
Name:AMI G VAIDYA DMD SC
Entity Type:Organization
Organization Name:AMI G VAIDYA DMD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:AMI
Authorized Official - Middle Name:
Authorized Official - Last Name:VAIDYA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:773-533-4323
Mailing Address - Street 1:3900 W MADISON ST
Mailing Address - Street 2:SUITE 12
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60624-2354
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3900 W MADISON ST
Practice Address - Street 2:SUITE 12
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60624-2354
Practice Address - Country:US
Practice Address - Phone:773-533-4323
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-16
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190279001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty