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General NPI Number Information
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NPI Number | 1083937742
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Entity Type | Organization
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Legal Business Name | APOLLO DENTAL CLINIC, LLC
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Dates
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Enumeration Date | 03/10/2010
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Last Update Date | 03/10/2010
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Provider Practice Location Address
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Address Line | 6121 WASHINGTON ST SUITE 203
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City | GURNEE
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State | IL
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Zip | 60031-5305
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Country | US
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Telephone | 630-267-4205
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Fax | 630-477-0447
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Provider Business Mailing Address
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Address Line | 6121 WASHINGTON ST SUITE 203
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City | GURNEE
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State | IL
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Zip | 60031-5305
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Country | US
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Telephone | 630-267-4205
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Fax | 630-477-0447
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Authorized Official
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Title or Position | MEMBER
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Name | DR. SUMRANA S AHMED
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Credential | DDS
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Telephone | 630-267-4205
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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 | 019026293
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License Number State | IL
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