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General NPI Number Information
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NPI Number | 1316463375
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Entity Type | Organization
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Legal Business Name | TITAN DENTAL PC
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Dates
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Enumeration Date | 08/21/2017
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Last Update Date | 08/21/2017
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Provider Practice Location Address
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Address Line | 13247 S BALTIMORE AVE
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City | CHICAGO
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State | IL
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Zip | 60633-1431
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Country | US
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Telephone | 773-646-4664
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Fax |
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Provider Business Mailing Address
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Address Line | 950 N CLARK ST UNIT I
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City | CHICAGO
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State | IL
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Zip | 60610-8702
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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 | OWNER
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Name | DR. ABHISHEK NAGARAJ
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Credential | DDS
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Telephone | 312-384-9493
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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 | 019029975
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License Number State | IL
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