Healthcare Provider Details

I. General information

NPI: 1578160990
Provider Name (Legal Business Name): DENTAL CARE CENTER JUSTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2020
Last Update Date: 11/29/2021
Certification Date: 11/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8021 W 79TH ST
JUSTICE IL
60458-1607
US

IV. Provider business mailing address

8021 W 79TH ST
JUSTICE IL
60458-1607
US

V. Phone/Fax

Practice location:
  • Phone: 224-366-0406
  • Fax:
Mailing address:
  • Phone:
  • 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 Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SYED REHMAN
Title or Position: OWNER
Credential: DMD
Phone: 224-366-0406