Healthcare Provider Details

I. General information

NPI: 1770095028
Provider Name (Legal Business Name): CHICAGO LAKE FAMILY DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2017
Last Update Date: 10/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 CHICAGO AVE
MINNEAPOLIS MN
55407-1322
US

IV. Provider business mailing address

4893 BOATMAN LN
INVER GROVE HEIGHTS MN
55076-1160
US

V. Phone/Fax

Practice location:
  • Phone: 612-823-2080
  • Fax:
Mailing address:
  • Phone:
  • 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. ALI BARBARAWI
Title or Position: GENERAL DENTIST
Credential: DMD
Phone: 612-823-2080