Healthcare Provider Details

I. General information

NPI: 1568917508
Provider Name (Legal Business Name): DENTAL SHINE II P.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2016
Last Update Date: 08/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11830 S ROUTE 59 SUITE 110
PLAINFIELD IL
60585-5894
US

IV. Provider business mailing address

11830 S ROUTE 59 SUITE 110
PLAINFIELD IL
60585-5894
US

V. Phone/Fax

Practice location:
  • Phone: 815-609-0000
  • Fax:
Mailing address:
  • Phone: 815-609-0000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019026154
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: FIRAS EL-MUQDAD
Title or Position: PRESIDENT
Credential:
Phone: 708-769-1073