Healthcare Provider Details

I. General information

NPI: 1366867442
Provider Name (Legal Business Name): ERID ALIAJ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2014
Last Update Date: 05/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 N CLARK ST DENTAL DREAMS LLC DANIELLE THARP 6TH FLOOR
CHICAGO IL
60654-4712
US

IV. Provider business mailing address

350 N CLARK ST DENTAL DREAMS LLC DANIELLE THARP 6TH FLOOR
CHICAGO IL
60654-4712
US

V. Phone/Fax

Practice location:
  • Phone: 708-699-3080
  • Fax:
Mailing address:
  • Phone: 708-699-3080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019.030100
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: