Healthcare Provider Details

I. General information

NPI: 1114852530
Provider Name (Legal Business Name): WAUCONDA FAMILY DENTAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2026
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

157 CARDINAL DR
HAWTHORN WOODS IL
60047-7570
US

IV. Provider business mailing address

1424 S BUTTERFIELD RD
MUNDELEIN IL
60060-9424
US

V. Phone/Fax

Practice location:
  • Phone: 847-407-1411
  • Fax:
Mailing address:
  • Phone: 847-407-1411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: SADIA AHMED
Title or Position: OWNER
Credential:
Phone: 773-876-0829