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General NPI Number Information
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NPI Number | 1801190582
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Entity Type | Organization
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Legal Business Name | PARK WEST FAMILY DENTISTRY
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Dates
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Enumeration Date | 01/10/2011
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Last Update Date | 01/03/2012
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Provider Practice Location Address
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Address Line | 830 W DIVERSEY PKWY 2ND FLOOR
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City | CHICAGO
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State | IL
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Zip | 60614-1454
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Country | US
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Telephone | 773-880-6054
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Fax |
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Provider Business Mailing Address
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Address Line | 830 W DIVERSEY PKWY 2ND FLOOR
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City | CHICAGO
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State | IL
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Zip | 60614-1454
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Country | US
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Telephone | 773-880-6054
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Fax |
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Authorized Official
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Title or Position | DENTIST/OWNER
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Name | DR. FARIHA SIDDIQUI IMAM
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Credential | D.D.S.
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Telephone | 773-880-6054
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 019.027922
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License Number State | IL
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