Healthcare Provider Details

I. General information

NPI: 1164892006
Provider Name (Legal Business Name): HOLLAND DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2015
Last Update Date: 09/20/2022
Certification Date: 09/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 E 162ND ST
SOUTH HOLLAND IL
60473-2141
US

IV. Provider business mailing address

9618 SOUTHWEST HWY
OAK LAWN IL
60453-2862
US

V. Phone/Fax

Practice location:
  • Phone: 708-424-5901
  • Fax:
Mailing address:
  • Phone: 708-394-5100
  • Fax: 708-907-3165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number019027051
License Number StateIL

VIII. Authorized Official

Name: DR. AHMED RAMAHA
Title or Position: VOICE PRESIDENT
Credential:
Phone: 708-424-5901