=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396417580
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MY CARE DENTAL TINLEY PARK PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2021
-----------------------------------------------------
Last Update Date | 10/05/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18311 N CREEK DR STE A
-----------------------------------------------------
City | TINLEY PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60477-6204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-444-7288
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18311 N CREEK DR STE A
-----------------------------------------------------
City | TINLEY PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60477-6204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-444-7288
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR/ OWNER
-----------------------------------------------------
Name | OMAR SHALASH
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 917-993-2245
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------