Healthcare Provider Details

I. General information

NPI: 1417410127
Provider Name (Legal Business Name): ARCHER DENTISTRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2019
Last Update Date: 07/12/2021
Certification Date: 07/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3924 S ARCHER AVE UNIT DE
CHICAGO IL
60632-1116
US

IV. Provider business mailing address

3924 S ARCHER AVE UNIT D
CHICAGO IL
60632-1116
US

V. Phone/Fax

Practice location:
  • Phone: 630-247-7216
  • Fax:
Mailing address:
  • Phone: 630-247-7216
  • Fax: 773-787-2400

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: RAHUL JADHAV
Title or Position: OWNER
Credential:
Phone: 630-247-7216