Provider Demographics
NPI:1922248210
Name:NORTHWESTERN DENTAL CLINIC LTD
Entity Type:Organization
Organization Name:NORTHWESTERN DENTAL CLINIC LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALI
Authorized Official - Middle Name:
Authorized Official - Last Name:EKTERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-252-0033
Mailing Address - Street 1:2604 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-5235
Mailing Address - Country:US
Mailing Address - Phone:773-252-0033
Mailing Address - Fax:
Practice Address - Street 1:2604 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-5235
Practice Address - Country:US
Practice Address - Phone:773-252-0033
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-25
Last Update Date:2009-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019023897122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty