Healthcare Provider Details

I. General information

NPI: 1184990897
Provider Name (Legal Business Name): GLENLAKE DENTAL CARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2012
Last Update Date: 03/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

946 HARLEM AVE
GLENVIEW IL
60025-4275
US

IV. Provider business mailing address

946 HARLEM AVE
GLENVIEW IL
60025-4275
US

V. Phone/Fax

Practice location:
  • Phone: 847-724-3969
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State

VIII. Authorized Official

Name: MARY AFZALI
Title or Position: PRESIDENT
Credential: DDS
Phone: 847-724-3969