=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669622270
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SJA DENTAL LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/19/2008
-----------------------------------------------------
Last Update Date | 09/19/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4 S NORTHWEST HWY
-----------------------------------------------------
City | PALATINE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60074-6231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-358-7282
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 112 CRESCENT LN
-----------------------------------------------------
City | SCHAUMBURG
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60193-5715
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-962-3208
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | GENERAL DENTIST
-----------------------------------------------------
Name | DR. SEAN JARED ABRAMS
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 847-962-3208
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 019027014
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------