=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881306660
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OLIVE FAMILY DENTAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/23/2022
-----------------------------------------------------
Last Update Date | 12/23/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 120 W NORTH AVE
-----------------------------------------------------
City | NORTHLAKE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60164-2317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-498-0050
-----------------------------------------------------
Fax | 708-498-0047
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 120 W NORTH AVE
-----------------------------------------------------
City | NORTHLAKE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60164-2317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-498-0050
-----------------------------------------------------
Fax | 708-498-0047
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DMD
-----------------------------------------------------
Name | DR. SAMRA HUSSAIN
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 602-334-3950
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------