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General NPI Number Information
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NPI Number | 1295424620
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Entity Type | Organization
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Legal Business Name | SPARK DENTAL PC
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Dates
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Enumeration Date | 05/02/2023
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Last Update Date | 05/02/2023
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Provider Practice Location Address
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Address Line | 1050 S BARRINGTON RD STE A
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City | STREAMWOOD
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State | IL
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Zip | 60107-2464
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Country | US
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Telephone | 630-672-7877
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 597
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City | SOUTH ELGIN
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State | IL
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Zip | 60177-0597
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | NISHU SHARMA
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Credential |
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Telephone | 630-672-7877
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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