Healthcare Provider Details

I. General information

NPI: 1619630480
Provider Name (Legal Business Name): SEPI DASHTI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2021
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1954 W FOSTER AVE APT 1
CHICAGO IL
60640-1198
US

IV. Provider business mailing address

205 RIDGE RD APT 202
WILMETTE IL
60091-3273
US

V. Phone/Fax

Practice location:
  • Phone: 773-506-2033
  • Fax: 773-506-6300
Mailing address:
  • Phone: 312-477-1309
  • Fax: 773-506-6300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.033166
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: