Provider Demographics
NPI:1396995999
Name:YOUR FAMILY DENTIST
Entity type:Organization
Organization Name:YOUR FAMILY DENTIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EMAD
Authorized Official - Middle Name:E
Authorized Official - Last Name:AZAB
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-589-1400
Mailing Address - Street 1:8441 W LAWRENCE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60656-2953
Mailing Address - Country:US
Mailing Address - Phone:773-589-1400
Mailing Address - Fax:773-589-1408
Practice Address - Street 1:8441 W LAWRENCE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60656-2953
Practice Address - Country:US
Practice Address - Phone:773-589-1400
Practice Address - Fax:773-589-1408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-19
Last Update Date:2008-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-023605122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1001115Medicaid