Healthcare Provider Details

I. General information

NPI: 1447086772
Provider Name (Legal Business Name): TEETH BOUTIQUE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2024
Last Update Date: 09/13/2024
Certification Date: 09/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1933 W IRVING PARK RD STE 1
CHICAGO IL
60613-5182
US

IV. Provider business mailing address

1933 W IRVING PARK RD STE 1
CHICAGO IL
60613-5182
US

V. Phone/Fax

Practice location:
  • Phone: 773-857-2280
  • Fax: 773-857-2260
Mailing address:
  • Phone:
  • 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 Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. RIZWANA MASKATIYA
Title or Position: OWNER
Credential:
Phone: 773-857-2280