Healthcare Provider Details

I. General information

NPI: 1265504617
Provider Name (Legal Business Name): ARDESHIR RAGHIAN D.D.S., P.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 01/20/2025
Certification Date: 01/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5841 W BELMONT AVE
CHICAGO IL
60634-5201
US

IV. Provider business mailing address

5841 W BELMONT AVE
CHICAGO IL
60634-5201
US

V. Phone/Fax

Practice location:
  • Phone: 773-622-3454
  • Fax: 773-622-0990
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019-024426
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number021002028
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: