Provider Demographics
NPI:1942653738
Name:DENTAL DIAGNOSTIC IMAGING
Entity Type:Organization
Organization Name:DENTAL DIAGNOSTIC IMAGING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MITRA
Authorized Official - Middle Name:
Authorized Official - Last Name:SADRAMELI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:312-966-6307
Mailing Address - Street 1:1201 S PRAIRIE AVE
Mailing Address - Street 2:4901
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-3325
Mailing Address - Country:US
Mailing Address - Phone:312-966-6307
Mailing Address - Fax:
Practice Address - Street 1:1201 S PRAIRIE AVE
Practice Address - Street 2:4901
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60605-3325
Practice Address - Country:US
Practice Address - Phone:312-966-6307
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-18
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0304341223X0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0008XDental ProvidersDentistOral and Maxillofacial RadiologyGroup - Single Specialty