Provider Demographics
NPI:1801190582
Name:PARK WEST FAMILY DENTISTRY
Entity type:Organization
Organization Name:PARK WEST FAMILY DENTISTRY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FARIHA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIDDIQUI IMAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-880-6054
Mailing Address - Street 1:830 W DIVERSEY PKWY
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-1454
Mailing Address - Country:US
Mailing Address - Phone:773-880-6054
Mailing Address - Fax:
Practice Address - Street 1:830 W DIVERSEY PKWY
Practice Address - Street 2:2ND FLOOR
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-1454
Practice Address - Country:US
Practice Address - Phone:773-880-6054
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-10
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0279221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty