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General NPI Number Information
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NPI Number | 1750775276
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Entity Type | Organization
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Legal Business Name | HEALTHY SMILES OF LA GRANGE, PC
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Dates
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Enumeration Date | 03/23/2015
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Last Update Date | 03/23/2015
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Provider Practice Location Address
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Address Line | 1400 W 47TH ST UNIT 7
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City | LA GRANGE
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State | IL
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Zip | 60525-6141
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Country | US
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Telephone | 708-482-4420
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Fax |
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Provider Business Mailing Address
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Address Line | 1400 W 47TH ST UNIT 7
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City | LA GRANGE
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State | IL
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Zip | 60525-6141
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Country | US
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Telephone | 708-482-4420
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Fax |
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Authorized Official
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Title or Position | GENERAL DENTIST
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Name | DR. ISAAC A QURESHI
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Credential | DDS
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Telephone | 708-482-4420
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 019029531
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License Number State | IL
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