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General NPI Number Information
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NPI Number | 1063820694
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Entity Type | Organization
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Legal Business Name | LAKESIDE DENTAL CENTER
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Dates
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Enumeration Date | 07/28/2014
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Last Update Date | 07/28/2014
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Provider Practice Location Address
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Address Line | 4945 W GRAND AVE
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City | CHICAGO
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State | IL
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Zip | 60639-4412
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Country | US
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Telephone | 224-366-0498
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Fax |
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Provider Business Mailing Address
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Address Line | 2218 S MICHIGAN AVE 2
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City | CHICAGO
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State | IL
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Zip | 60616-2126
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Country | US
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Telephone | 312-842-7133
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Fax | 312-842-2082
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Authorized Official
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Title or Position | OWNER
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Name | HUSSAIN ALI
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Credential | DDS
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Telephone | 224-366-0498
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019029848
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License Number State | IL
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