Healthcare Provider Details

I. General information

NPI: 1407569247
Provider Name (Legal Business Name): AMANA FAMILY DENTAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2022
Last Update Date: 12/26/2022
Certification Date: 12/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9544 W 147TH ST
ORLAND PARK IL
60462-2502
US

IV. Provider business mailing address

9544 W 147TH ST
ORLAND PARK IL
60462-2502
US

V. Phone/Fax

Practice location:
  • Phone: 708-981-3433
  • Fax: 708-966-0082
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: HICHAM RIBA
Title or Position: DDS
Credential:
Phone: 708-981-3433