Provider Demographics
NPI:1245893189
Name:SECURE DENTAL X PLLC
Entity type:Organization
Organization Name:SECURE DENTAL X PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:NAZISH
Authorized Official - Middle Name:
Authorized Official - Last Name:JAFRI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:815-708-2762
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:
Mailing Address - Fax:
Practice Address - Street 1:1828 W FOSTER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-1479
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:2019-04-16
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty