=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578197026
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 1ST FAMILY DENTAL OF WEST ROSELAND PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/24/2020
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 701 W 111TH ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60628-3902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-995-1234
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 701 W 111TH ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60628-3902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-995-1234
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | VESNA BELKIC
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 630-433-4962
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------