Provider Demographics
NPI:1780848945
Name:FAMILY DENTAL CLINIC, PC
Entity type:Organization
Organization Name:FAMILY DENTAL CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:ZAFFARKHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-463-1904
Mailing Address - Street 1:3211 W LAWRENCE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-5208
Mailing Address - Country:US
Mailing Address - Phone:773-463-1904
Mailing Address - Fax:773-463-1257
Practice Address - Street 1:3211 W LAWRENCE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-5208
Practice Address - Country:US
Practice Address - Phone:773-463-1904
Practice Address - Fax:773-463-1257
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-16
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL01901529302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL14177013061Medicaid