=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356818207
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCE FAMILY DENTAL CARE, LTD.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/30/2018
-----------------------------------------------------
Last Update Date | 10/30/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 105 REVERE DR STE E
-----------------------------------------------------
City | NORTHBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60062-1594
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 224-282-8191
-----------------------------------------------------
Fax | 224-282-8167
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 105 REVERE DR STE E
-----------------------------------------------------
City | NORTHBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60062-1594
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 224-282-8191
-----------------------------------------------------
Fax | 224-282-8167
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. PIROOZ ZOMORRODI
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 630-802-3515
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------