Healthcare Provider Details

I. General information

NPI: 1447767546
Provider Name (Legal Business Name): CICERO DENTAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2018
Last Update Date: 05/23/2022
Certification Date: 05/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1639 S CICERO AVE
CICERO IL
60804-1520
US

IV. Provider business mailing address

1639 S CICERO AVE
CICERO IL
60804-1520
US

V. Phone/Fax

Practice location:
  • Phone: 708-477-6717
  • Fax: 708-477-6434
Mailing address:
  • Phone: 708-477-6717
  • Fax: 708-477-6434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1184826174
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1710977939
License Number StateIL

VIII. Authorized Official

Name: HAMZA MOHAMMED
Title or Position: ADMINISTRATOR
Credential:
Phone: 630-437-0774