Provider Demographics
NPI:1295122539
Name:MCLEAN DENTAL CLINIC, P.C.
Entity type:Organization
Organization Name:MCLEAN DENTAL CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MUMTAZ
Authorized Official - Middle Name:
Authorized Official - Last Name:SIDDIQUE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSC
Authorized Official - Phone:847-931-9744
Mailing Address - Street 1:552 N MCLEAN BLVD
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-3242
Mailing Address - Country:US
Mailing Address - Phone:847-931-9744
Mailing Address - Fax:847-931-7726
Practice Address - Street 1:552 N MCLEAN BLVD
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-3242
Practice Address - Country:US
Practice Address - Phone:847-931-9744
Practice Address - Fax:847-931-7726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-24
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019022632261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019022632Medicaid