Healthcare Provider Details

I. General information

NPI: 1104751551
Provider Name (Legal Business Name): SECURE DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2026
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5621 W MONTROSE AVE
CHICAGO IL
60634-1830
US

IV. Provider business mailing address

502 RIVERSIDE DR
EAST PEORIA IL
61611-2068
US

V. Phone/Fax

Practice location:
  • Phone: 733-427-1000
  • Fax:
Mailing address:
  • Phone: 309-606-5008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NAZISH HASAN JAFRI
Title or Position: OWNER DENTIST
Credential: DDS
Phone: 309-606-5008