Healthcare Provider Details

I. General information

NPI: 1235733858
Provider Name (Legal Business Name): SECURE DENTAL III LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2020
Last Update Date: 11/24/2020
Certification Date: 11/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3820 CENTRAL AVE # 2324
LAKE STATION IN
46405-2380
US

IV. Provider business mailing address

309 BROOKSTONE DR
EAST PEORIA IL
61611-8300
US

V. Phone/Fax

Practice location:
  • Phone: 219-962-8666
  • Fax:
Mailing address:
  • Phone: 815-708-2762
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. NAZISH HASAN JAFRI
Title or Position: OWNER DENTIST
Credential: DDS
Phone: 815-708-2762