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General NPI Number Information
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NPI Number | 1184866329
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Entity Type | Organization
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Legal Business Name | ADVANCED DENTISTRY AT MORTON GROVE
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Dates
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Enumeration Date | 04/02/2009
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Last Update Date | 03/11/2020
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Provider Practice Location Address
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Address Line | 5821 DEMPSTER ST
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City | MORTON GROVE
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State | IL
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Zip | 60053-3028
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Country | US
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Telephone | 847-581-1942
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Fax | 847-581-1943
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Provider Business Mailing Address
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Address Line | 5821 DEMPSTER ST
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City | MORTON GROVE
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State | IL
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Zip | 60053-3028
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Country | US
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Telephone | 847-581-1942
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Fax | 847-581-1943
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Authorized Official
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Title or Position | PRESIDENT
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Name | BEHZAD SANEI
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Credential | DMD
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Telephone | 773-383-0868
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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 | 019.027311
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License Number State | IL
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