=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871845131
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEDFORD DENTAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2012
-----------------------------------------------------
Last Update Date | 10/11/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7250 S CICERO AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60629-5849
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-810-2948
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7250 S CICERO AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60629-5849
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-810-2948
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | SINAN RAZZAK
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 312-810-2948
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 019027470
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------