Healthcare Provider Details

I. General information

NPI: 1104953827
Provider Name (Legal Business Name): FAUZIA KHAN-ALSIKAFI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 10/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 LAKE ST
OAK PARK IL
60302-2612
US

IV. Provider business mailing address

238 MOFFETT RD
LAKE BLUFF IL
60044-2814
US

V. Phone/Fax

Practice location:
  • Phone: 708-848-0528
  • Fax:
Mailing address:
  • Phone: 312-404-2635
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019-025320
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: