Provider Demographics
NPI:1902131444
Name:DENTAL SHINE III P C
Entity Type:Organization
Organization Name:DENTAL SHINE III P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FIRAS
Authorized Official - Middle Name:
Authorized Official - Last Name:EL-MUQDAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-776-6666
Mailing Address - Street 1:2902 W 63RD ST.
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60629
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2902 W 63RD ST.
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629
Practice Address - Country:US
Practice Address - Phone:773-776-6666
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-15
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019026154261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental