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General NPI Number Information
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NPI Number | 1578886206
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Entity Type | Organization
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Legal Business Name | OLD ORCHARD DENTAL GROUP P.C.
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Dates
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Enumeration Date | 03/09/2010
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Last Update Date | 03/09/2010
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Provider Practice Location Address
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Address Line | 9631 GROSS POINT RD SUITE 4
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City | SKOKIE
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State | IL
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Zip | 60076-1264
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Country | US
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Telephone | 312-402-7414
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Fax |
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Provider Business Mailing Address
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Address Line | 9631 GROSS POINT RD SUITE 4
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City | SKOKIE
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State | IL
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Zip | 60076-1264
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | ATOSA SARRAFI
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Credential | DMD
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Telephone | 312-402-7414
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number |
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License Number State | IL
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