Healthcare Provider Details

I. General information

NPI: 1689934754
Provider Name (Legal Business Name): WEST SUBURBAN FAMILY DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2012
Last Update Date: 05/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 OAK BROOK CENTER MALL SUITE#802
OAK BROOK IL
60523-1806
US

IV. Provider business mailing address

120 OAK BROOK CENTER MALL SUITE#802
OAK BROOK IL
60523-1806
US

V. Phone/Fax

Practice location:
  • Phone: 630-571-3030
  • Fax: 630-571-1977
Mailing address:
  • Phone: 630-571-3030
  • Fax: 630-571-1977

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: MR. RAUL T ALEMAN
Title or Position: DDS
Credential: DDS
Phone: 630-571-3030