=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780452706
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ARTDENTISTREE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/19/2023
-----------------------------------------------------
Last Update Date | 12/19/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6319 FAIRVIEW AVE STE 103
-----------------------------------------------------
City | WESTMONT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60559-2889
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-827-5250
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9 ARCADIA CT
-----------------------------------------------------
City | BURR RIDGE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60527-0701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. TARANNUM MARYA
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 415-827-5250
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------