Provider Demographics
NPI:1104077692
Name:PERFECT DENTAL SMILE, LTD.
Entity type:Organization
Organization Name:PERFECT DENTAL SMILE, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BUSHRA
Authorized Official - Middle Name:AHMED
Authorized Official - Last Name:AL AZZAWI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-561-2808
Mailing Address - Street 1:2545 W PETERSON AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-4091
Mailing Address - Country:US
Mailing Address - Phone:773-561-2808
Mailing Address - Fax:773-561-2809
Practice Address - Street 1:2545 W PETERSON AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-4091
Practice Address - Country:US
Practice Address - Phone:773-561-2808
Practice Address - Fax:773-561-2809
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PERFECT DENTAL SMILE, LTS.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-02
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019024872122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty