Provider Demographics
NPI:1205084456
Name:MOHAMMAD R EKHTERA, DDS.PC
Entity type:Organization
Organization Name:MOHAMMAD R EKHTERA, DDS.PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:REZA
Authorized Official - Last Name:EKHTERA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-920-0320
Mailing Address - Street 1:1700 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-2421
Mailing Address - Country:US
Mailing Address - Phone:847-920-0320
Mailing Address - Fax:
Practice Address - Street 1:4235 W ARMITAGE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-3646
Practice Address - Country:US
Practice Address - Phone:773-342-1600
Practice Address - Fax:773-342-1601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-29
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL319014411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1005436Medicaid