Provider Demographics
NPI:1144958067
Name:ICO DENTAL, LLC
Entity type:Organization
Organization Name:ICO DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THAER
Authorized Official - Middle Name:
Authorized Official - Last Name:AL AZZAWI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:713-382-8654
Mailing Address - Street 1:343 W WOLF POINT PLZ UNIT 1404
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-0103
Mailing Address - Country:US
Mailing Address - Phone:713-382-8654
Mailing Address - Fax:
Practice Address - Street 1:4200 W PETERSON AVE STE 136
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-6052
Practice Address - Country:US
Practice Address - Phone:773-286-5286
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-09
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental