Provider Demographics
NPI:1801186986
Name:ADVANCED DENTAL CARE
Entity Type:Organization
Organization Name:ADVANCED DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:FATEMEH
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAGHANI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-871-0336
Mailing Address - Street 1:2457 N LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-8509
Mailing Address - Country:US
Mailing Address - Phone:773-871-0336
Mailing Address - Fax:773-871-0981
Practice Address - Street 1:2457 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-8509
Practice Address - Country:US
Practice Address - Phone:773-871-0336
Practice Address - Fax:773-871-0981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-11
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223E0200X, 1223G0001X, 1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty