Healthcare Provider Details

I. General information

NPI: 1063862431
Provider Name (Legal Business Name): DENTAL STARZ 3 L.L.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2016
Last Update Date: 06/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 N LARKIN AVE SUITE 504 A
CREST HILL IL
60403-1970
US

IV. Provider business mailing address

1701 N LARKIN AVE SUITE 504 A
CREST HILL IL
60403-1970
US

V. Phone/Fax

Practice location:
  • Phone: 708-562-5100
  • Fax:
Mailing address:
  • Phone: 708-562-5100
  • 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 Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. MOHAMMED ASIM
Title or Position: GENERAL DENTIST
Credential: D.D.S
Phone: 708-562-5100