=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417354093
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ARDESHIR RAGHIAN DDS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/26/2014
-----------------------------------------------------
Last Update Date | 04/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5841 W BELMONT AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60634-5201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-622-3454
-----------------------------------------------------
Fax | 773-622-0990
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5841 W BELMONT AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60634-5201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-622-3454
-----------------------------------------------------
Fax | 773-622-0990
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. ARDESHIR RAGHIAN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 773-622-3454
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 019024426
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------