=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477162501
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAHDI DENTAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2020
-----------------------------------------------------
Last Update Date | 07/24/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 125 S BLOOMINGDALE RD STE 9
-----------------------------------------------------
City | BLOOMINGDALE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60108-1216
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-969-4248
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 125 S BLOOMINGDALE RD STE 9
-----------------------------------------------------
City | BLOOMINGDALE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60108-1216
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-969-4248
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DR / OWNER
-----------------------------------------------------
Name | DR. MOHAMMED MAHDI
-----------------------------------------------------
Credential | DMD , MS
-----------------------------------------------------
Telephone | 203-969-4248
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------