Provider Demographics
NPI:1710162581
Name:PRESTIGE DENTAL P C
Entity Type:Organization
Organization Name:PRESTIGE DENTAL P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MOEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:IKRAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:630-213-0666
Mailing Address - Street 1:125 E IRVING PARK RD
Mailing Address - Street 2:
Mailing Address - City:STREAMWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60107-2950
Mailing Address - Country:US
Mailing Address - Phone:630-213-0682
Mailing Address - Fax:630-213-0685
Practice Address - Street 1:125 E IRVING PARK RD
Practice Address - Street 2:
Practice Address - City:STREAMWOOD
Practice Address - State:IL
Practice Address - Zip Code:60107-2950
Practice Address - Country:US
Practice Address - Phone:630-213-0682
Practice Address - Fax:630-213-0685
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-29
Last Update Date:2007-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL181058Medicaid