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General NPI Number Information
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NPI Number | 1962638817
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Entity Type | Organization
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Legal Business Name | UNIVERSITY DENTAL ASSOCIATES
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Dates
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Enumeration Date | 06/05/2009
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Last Update Date | 06/05/2009
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Provider Practice Location Address
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Address Line | 1424 E 53RD ST STE 28 SUITE 209
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City | CHICAGO
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State | IL
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Zip | 60615-4553
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Country | US
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Telephone | 773-363-6009
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Fax |
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Provider Business Mailing Address
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Address Line | 1424 E 53RD ST STE 28 SUITE 209
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City | CHICAGO
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State | IL
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Zip | 60615-4553
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Country | US
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Telephone | 773-363-6009
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | RAJAN SHARMA
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Credential |
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Telephone | 773-363-6009
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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 | 019-021911
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License Number State | IL
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