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General NPI Number Information
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NPI Number | 1447767546
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Entity Type | Organization
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Legal Business Name | CICERO DENTAL CENTER LLC
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Dates
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Enumeration Date | 01/10/2018
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Last Update Date | 05/23/2022
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Provider Practice Location Address
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Address Line | 1639 S CICERO AVE
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City | CICERO
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State | IL
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Zip | 60804-1520
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Country | US
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Telephone | 708-477-6717
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Fax | 708-477-6434
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Provider Business Mailing Address
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Address Line | 1639 S CICERO AVE
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City | CICERO
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State | IL
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Zip | 60804-1520
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Country | US
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Telephone | 708-477-6717
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Fax | 708-477-6434
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | HAMZA MOHAMMED
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Credential |
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Telephone | 630-437-0774
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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 | 1184826174
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 1710977939
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License Number State | IL
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