Provider Demographics
NPI:1699837187
Name:FAYZ, BITA MEDINEJAD (DDS)
Entity Type:Individual
Prefix:DR
First Name:BITA
Middle Name:MEDINEJAD
Last Name:FAYZ
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1525 E 53RD ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-4557
Mailing Address - Country:US
Mailing Address - Phone:773-955-5000
Mailing Address - Fax:773-955-5838
Practice Address - Street 1:1525 E 53RD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-4557
Practice Address - Country:US
Practice Address - Phone:773-955-5000
Practice Address - Fax:773-955-5838
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL190231521223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics