=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891188488
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRANQUIL DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2015
-----------------------------------------------------
Last Update Date | 03/06/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3450 MONTGOMERY RD UNIT 8
-----------------------------------------------------
City | AURORA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60504-3151
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-499-5555
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3450 MONTGOMERY RD UNIT 8
-----------------------------------------------------
City | AURORA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60504-3151
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-499-5555
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ALI KHAN
-----------------------------------------------------
Credential | D.D.S
-----------------------------------------------------
Telephone | 213-820-6487
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------