=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356707764
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAIRVIEW DENTAL CARE GROUP P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/14/2016
-----------------------------------------------------
Last Update Date | 01/14/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6317 FAIRVIEW AVE SUITE 6
-----------------------------------------------------
City | WESTMONT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60559-2887
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-852-5353
-----------------------------------------------------
Fax | 630-968-0958
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6317 FAIRVIEW AVE SUITE 6
-----------------------------------------------------
City | WESTMONT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60559-2887
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-852-5353
-----------------------------------------------------
Fax | 630-968-0958
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | MR. ROSHAN PARIKH
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 630-852-5353
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------