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General NPI Number Information
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NPI Number | 1730747338
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Entity Type | Organization
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Legal Business Name | MIDWAY FAMILY DENTAL, LLC
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Dates
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Enumeration Date | 05/30/2019
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Last Update Date | 05/30/2019
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Provider Practice Location Address
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Address Line | 6258 S PULASKI RD
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City | CHICAGO
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State | IL
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Zip | 60629-4610
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Country | US
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Telephone | 773-777-6363
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Fax |
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Provider Business Mailing Address
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Address Line | 6258 S PULASKI RD
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City | CHICAGO
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State | IL
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Zip | 60629-4610
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Country | US
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Telephone | 773-777-6363
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Fax |
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Authorized Official
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Title or Position | MANAGER/OWNER
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Name | DR. GHAZAL S KERMANI
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Credential | DDS
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Telephone | 949-701-5320
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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