=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891002994
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AJAY DAS DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/10/2010
-----------------------------------------------------
Last Update Date | 01/14/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2034 N STATE ROUTE 50
-----------------------------------------------------
City | BOURBONNAIS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60914-4410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-460-7760
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2034 N STATE ROUTE 50
-----------------------------------------------------
City | BOURBONNAIS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60914-4410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-460-7760
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 14650
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------