Healthcare Provider Details

I. General information

NPI: 1144587882
Provider Name (Legal Business Name): FAMILIA DENTAL WHEELING 3 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2012
Last Update Date: 04/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

542 W DUNDEE RD SUITE B
WHEELING IL
60090-3227
US

IV. Provider business mailing address

2050 E ALGONQUIN RD SUITE 610
SCHAUMBURG IL
60173-4144
US

V. Phone/Fax

Practice location:
  • Phone: 888-988-4066
  • Fax: 847-496-7202
Mailing address:
  • Phone: 888-988-4066
  • Fax: 847-496-7202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. KOUSHAN AZAD
Title or Position: OWNER
Credential: DMD
Phone: 888-988-4066