Provider Demographics
NPI:1205285293
Name:FAMILY DENTAL OF ROSCOE INC
Entity type:Organization
Organization Name:FAMILY DENTAL OF ROSCOE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:OLENA
Authorized Official - Middle Name:
Authorized Official - Last Name:OBEID
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-679-2419
Mailing Address - Street 1:3332 N WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-6213
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3332 N WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-6213
Practice Address - Country:US
Practice Address - Phone:773-679-2419
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-09
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.028238261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental