Provider Demographics
NPI:1063862431
Name:DENTAL STARZ 3 L.L.C
Entity type:Organization
Organization Name:DENTAL STARZ 3 L.L.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMMED
Authorized Official - Middle Name:
Authorized Official - Last Name:ASIM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:708-562-5100
Mailing Address - Street 1:1701 N LARKIN AVE
Mailing Address - Street 2:SUITE 504 A
Mailing Address - City:CREST HILL
Mailing Address - State:IL
Mailing Address - Zip Code:60403-1970
Mailing Address - Country:US
Mailing Address - Phone:708-562-5100
Mailing Address - Fax:
Practice Address - Street 1:1701 N LARKIN AVE
Practice Address - Street 2:SUITE 504 A
Practice Address - City:CREST HILL
Practice Address - State:IL
Practice Address - Zip Code:60403-1970
Practice Address - Country:US
Practice Address - Phone:708-562-5100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-16
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty