| NPI |
1568836617 |
The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number. |
| Entity Type Code |
2 |
|
| Employer Identification Number EIN |
|
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
| Provider Organization Name Legal Business Name |
INTERNATIONAL DENTAL OF BRIDGEVIEW LLC |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
| Provider First Line Business Practice Location Address |
7124 W 83RD ST |
The first line location address of the provider
being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box. |
| Provider Second Line Business Practice Location Address |
SUITE E |
The second line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot
include a Post Office box. |
| Provider Business Practice Location Address City Name |
BRIDGEVIEW |
|
| Provider Business Practice Location Address State Name |
IL |
The State code in the location of the provider
being identified. |
| Provider Business Practice Location Address Postal Code |
604554034 |
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. |
| Provider Business Practice Location Address Country Code If outside U S |
US |
The country code in the location address of the provider being identified. |
| Provider Business Practice Location Address Telephone Number |
7082610861 |
The telephone number associated with the location address of the provider being identified. |
| Provider Enumeration Date |
11/29/2015 |
The date the provider was assigned a unique identifier (assigned an NPI). |
| Last Update Date |
3/7/2016 |
The date that a record was last updated or changed. |
| Authorized Official Last Name |
AKHRAS |
The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider. |
| Authorized Official First Name |
SALEH |
The first name of the authorized official. |
| Authorized Official Title or Position |
PRESIDENT |
The title or position of the authorized official. |
| Authorized Official Telephone Number |
7082610861 |
The 10-position telephone number of the authorized official. |
| Healthcare Provider Taxonomy Code 1 |
261QD0000X |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
| Healthcare Provider Primary Taxonomy Switch 1 |
Y |
|
| Is Organization Subpart |
N |
|
| Authorized Official Name Prefix Text |
DR. |
|
| Authorized Official Credential Text |
D.D.S. |
|