Provider Demographics
NPI:1760712855
Name:TWO RIVERS DENTAL
Entity Type:Organization
Organization Name:TWO RIVERS DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SOHAIL
Authorized Official - Middle Name:S
Authorized Official - Last Name:SHAFI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-842-3705
Mailing Address - Street 1:1730 PARK ST STE 106
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-2609
Mailing Address - Country:US
Mailing Address - Phone:630-759-9929
Mailing Address - Fax:630-759-9922
Practice Address - Street 1:1196 W BOUGHTON RD
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-6567
Practice Address - Country:US
Practice Address - Phone:630-759-9929
Practice Address - Fax:630-759-9922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-12
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190248091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty