Healthcare Provider Details

I. General information

NPI: 1801985338
Provider Name (Legal Business Name): INDERJIT BAWA DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 02/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4239 S ARCHER AVE
CHICAGO IL
60632-2568
US

IV. Provider business mailing address

4239 S ARCHER AVE
CHICAGO IL
60632-2568
US

V. Phone/Fax

Practice location:
  • Phone: 773-523-7525
  • Fax: 773-523-0609
Mailing address:
  • Phone: 773-523-7525
  • Fax: 773-523-0609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019024278
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: