Provider Demographics
NPI:1770661019
Name:AGARWAL DENTAL CLINIC
Entity Type:Organization
Organization Name:AGARWAL DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-257-6770
Mailing Address - Street 1:1501 S CALIFORNIA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-1732
Mailing Address - Country:US
Mailing Address - Phone:773-257-6770
Mailing Address - Fax:
Practice Address - Street 1:1415 EMERALD AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60411-3517
Practice Address - Country:US
Practice Address - Phone:708-756-7384
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ACCESS COMMUNITY HEALTH NETWORK
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-02
Last Update Date:2007-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental