Provider Demographics
NPI:1932672052
Name:SECURE DENTAL IX LLC
Entity Type:Organization
Organization Name:SECURE DENTAL IX LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NAZISH
Authorized Official - Middle Name:HASAN
Authorized Official - Last Name:JAFRI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-606-5008
Mailing Address - Street 1:502 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:EAST PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61611-2068
Mailing Address - Country:US
Mailing Address - Phone:309-606-5008
Mailing Address - Fax:
Practice Address - Street 1:2381 E 80TH AVE
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-5722
Practice Address - Country:US
Practice Address - Phone:309-606-5008
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-11
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty