=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598932030
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EAST ERIE DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2008
-----------------------------------------------------
Last Update Date | 05/14/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 233 E ERIE ST SUITE 406
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60611-2926
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-587-0200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 233 E ERIE ST SUITE 406
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60611-2926
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-587-0200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | NASRIN AZIMZADEH
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 312-587-0200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 019024883
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------