=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174850317
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EMAN ALI SHIRAZI DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2009
-----------------------------------------------------
Last Update Date | 11/09/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2250 W ALGONQUIN RD SUITE 101
-----------------------------------------------------
City | LAKE IN THE HILLS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60156-1289
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-854-2970
-----------------------------------------------------
Fax | 847-854-3171
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2250 W ALGONQUIN RD SUITE 101
-----------------------------------------------------
City | LAKE IN THE HILLS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60156-1289
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-854-2970
-----------------------------------------------------
Fax | 847-854-3171
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 1902-5647
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------