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General NPI Number Information
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NPI Number | 1023276292
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Entity Type | Organization
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Legal Business Name | DENTAL STARZ, LLC
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Dates
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Enumeration Date | 05/23/2008
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Last Update Date | 05/23/2008
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Provider Practice Location Address
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Address Line | 2121 S WOLF RD APT 412
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City | HILLSIDE
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State | IL
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Zip | 60162-2144
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Country | US
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Telephone | 630-290-2023
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Fax |
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Provider Business Mailing Address
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Address Line | 75 W NORTH AVE # 400
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City | NORTHLAKE
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State | IL
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Zip | 60164-2306
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. ILYAS MOHAMMED AHMED
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Credential | D.D.S.
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Telephone | 630-290-2023
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 019-026721
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License Number State | IL
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