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General NPI Number Information
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NPI Number | 1285170084
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Entity Type | Organization
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Legal Business Name | LAWNDALE DENTAL LLC
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Dates
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Enumeration Date | 01/17/2017
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Last Update Date | 01/17/2017
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Provider Practice Location Address
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Address Line | 3600 W ROOSEVELT RD
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City | CHICAGO
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State | IL
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Zip | 60624-4225
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Country | US
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Telephone | 773-565-4042
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Fax |
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Provider Business Mailing Address
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Address Line | 3600 W ROOSEVELT RD
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City | CHICAGO
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State | IL
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Zip | 60624-4225
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Country | US
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Telephone | 773-565-4042
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | SYED REHMAN
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Credential | DMD
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Telephone | 847-915-2827
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 019030260
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License Number State | IL
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