Healthcare Provider Details

I. General information

NPI: 1174916233
Provider Name (Legal Business Name): DHCCLTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2015
Last Update Date: 03/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 N WEBER RD 397
BOLINGBROOK IL
60490-1569
US

IV. Provider business mailing address

319 N WEBER RD 397
BOLINGBROOK IL
60490-1569
US

V. Phone/Fax

Practice location:
  • Phone: 773-656-3170
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019028978
License Number StateIL

VIII. Authorized Official

Name: DR. MOHAMED WAHEED
Title or Position: DENTIST
Credential:
Phone: 773-656-3170