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General NPI Number Information
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NPI Number | 1316675176
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Entity Type | Organization
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Legal Business Name | BERWYN DENTAL CLINIC
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Dates
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Enumeration Date | 08/10/2022
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Last Update Date | 08/22/2022
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Provider Practice Location Address
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Address Line | 6436 CERMAK RD
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City | BERWYN
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State | IL
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Zip | 60402-2310
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Country | US
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Telephone | 708-317-5264
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Fax | 708-317-5271
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Provider Business Mailing Address
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Address Line | 1600 E 93RD ST
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City | CHICAGO
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State | IL
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Zip | 60617-3607
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Country | US
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Telephone | 708-351-4562
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Fax | 773-530-7550
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Authorized Official
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Title or Position | OWNER
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Name | YAQIN DAWOUD
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Credential | DDS
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Telephone | 708-351-4562
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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 |
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License Number State |
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