Healthcare Provider Details

I. General information

NPI: 1366930604
Provider Name (Legal Business Name): PSP DENTAL SERVICES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2018
Last Update Date: 01/08/2025
Certification Date: 01/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5425 W 95TH ST
OAK LAWN IL
60453-2354
US

IV. Provider business mailing address

5425 W 95TH ST
OAK LAWN IL
60453-2354
US

V. Phone/Fax

Practice location:
  • Phone: 708-636-0565
  • Fax: 708-636-0566
Mailing address:
  • Phone: 708-636-0565
  • Fax: 708-636-0566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number StateIL

VIII. Authorized Official

Name: PARAJ PATEL
Title or Position: PRESIDENT
Credential: DMD
Phone: 201-303-8996