Healthcare Provider Details

I. General information

NPI: 1144839424
Provider Name (Legal Business Name): KEDZIE 47 DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2020
Last Update Date: 10/28/2021
Certification Date: 10/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4721 S KEDZIE AVE
CHICAGO IL
60632-3001
US

IV. Provider business mailing address

4721 S KEDZIE AVE
CHICAGO IL
60632-3001
US

V. Phone/Fax

Practice location:
  • Phone: 773-847-4444
  • Fax: 630-359-4933
Mailing address:
  • Phone: 630-501-0064
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MUZAFFAR MIRZA
Title or Position: PRESIDENT
Credential: DDS
Phone: 630-501-0064