Healthcare Provider Details

I. General information

NPI: 1053609701
Provider Name (Legal Business Name): HICHAM RIBA DDS P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2011
Last Update Date: 11/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2556 W NORTH AVE
CHICAGO IL
60647
US

IV. Provider business mailing address

2556 W NORTH AVE
CHICAGO IL
60647
US

V. Phone/Fax

Practice location:
  • Phone: 773-360-1281
  • Fax: 773-360-1285
Mailing address:
  • Phone: 773-360-1281
  • Fax: 773-360-1285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019024373
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019024373
License Number StateIL

VIII. Authorized Official

Name: MRS. ALICIA C KIEFFER
Title or Position: OPERATIONS MANAGER
Credential:
Phone: 708-819-0515