Provider Demographics
NPI:1750518502
Name:INTERNATIONAL DENTAL CENTER
Entity type:Organization
Organization Name:INTERNATIONAL DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RABEH
Authorized Official - Middle Name:
Authorized Official - Last Name:SALAMAH-MOAHAMMAD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-227-1245
Mailing Address - Street 1:18 S LARKIN AVE
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60436-1244
Mailing Address - Country:US
Mailing Address - Phone:815-730-1570
Mailing Address - Fax:
Practice Address - Street 1:18 S LARKIN AVE
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60436-1244
Practice Address - Country:US
Practice Address - Phone:815-730-1570
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-19
Last Update Date:2009-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019023066305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service