=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073628137
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | QT QUALITY DENTAL CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/20/2006
-----------------------------------------------------
Last Update Date | 01/11/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6804 W ARCHER
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60638
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-586-3366
-----------------------------------------------------
Fax | 773-586-9554
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6804 W ARCHER
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60638-2312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-586-3366
-----------------------------------------------------
Fax | 773-586-9554
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TU QUYNH NGUYEN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 773-586-3366
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------