Healthcare Provider Details

I. General information

NPI: 1093954091
Provider Name (Legal Business Name): EUCLID ADVANCED DENTISTRY, P.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2009
Last Update Date: 02/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 E EUCLID AVE STE B
MOUNT PROSPECT IL
60056-1214
US

IV. Provider business mailing address

409 E EUCLID AVE STE B
MOUNT PROSPECT IL
60056-1214
US

V. Phone/Fax

Practice location:
  • Phone: 847-368-0200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019027311
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number021002216
License Number StateIL

VIII. Authorized Official

Name: SABA KHAN
Title or Position: PRESIDENT
Credential:
Phone: 847-368-0200