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General NPI Number Information
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NPI Number | 1235400821
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Entity Type | Organization
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Legal Business Name | THE DENTAL LOFT, LLC
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Dates
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Enumeration Date | 01/13/2012
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Last Update Date | 08/03/2015
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Provider Practice Location Address
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Address Line | 1 W HARRIS AVE SECOND FLOOR, SUITE A
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City | LA GRANGE
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State | IL
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Zip | 60525-2496
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Country | US
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Telephone | 708-482-0702
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Fax |
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Provider Business Mailing Address
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Address Line | 1 W HARRIS AVE SUITE 2A
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City | LA GRANGE
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State | IL
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Zip | 60525-2496
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Country | US
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Telephone | 708-482-0702
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | DR. ELHAM SHARAF-ELDEEN
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Credential | DMD
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Telephone | 708-482-0702
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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 | 019.027663
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019.028065
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License Number State | IL
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