MEDICARE: FAMILIA DENTAL ESL 4 LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1801151063
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILIA DENTAL ESL 4 LLC

Provider Business Mailing Address
First Line	:	2050 E ALGONQUIN RD
Second Line	:	SUITE 610
City	:	SCHAUMBURG
State	:	IL
Zip	:	60173-4144
Country	:	US
Telephone Number	:	888-988-4066
Fax Number	:	847-496-7603

Provider Business Practice Location Address
First Line	:	2608 STATE ST
Second Line	:
City	:	EAST SAINT LOUIS
State	:	IL
Zip	:	62205-2325
Country	:	US
Telephone Number	:	888-988-4066
Fax Number	:	847-496-7603

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. KOUSHAN AZAD
Credential	:	DMDM
Telephone Number	:	888-988-4066

Provider Enumeration Date	:	07/12/2012
Last Update Date	:	07/12/2012

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