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General NPI Number Information
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NPI Number | 1821492463
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Entity Type | Organization
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Legal Business Name | PEARL DENTAL, LLC
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Dates
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Enumeration Date | 10/10/2014
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Last Update Date | 10/10/2014
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Provider Practice Location Address
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Address Line | 4707 N PULASKI RD STE 103
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City | CHICAGO
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State | IL
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Zip | 60630-4312
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Country | US
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Telephone | 773-604-5050
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Fax | 773-604-5030
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Provider Business Mailing Address
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Address Line | 4707 N PULASKI RD STE 103
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City | CHICAGO
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State | IL
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Zip | 60630-4312
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Country | US
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Telephone | 773-604-5050
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Fax | 773-604-5030
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Authorized Official
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Title or Position | OWNER
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Name | MR. FAWAZ KANNOUT
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Credential | D.D.S
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Telephone | 773-604-5050
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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 | 019024870
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License Number State | IL
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