Provider Demographics
NPI:1306423314
Name:BANSAL, ROHAN
Entity type:Individual
Prefix:
First Name:ROHAN
Middle Name:
Last Name:BANSAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8704 RIDGELAND AVE
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-1068
Mailing Address - Country:US
Mailing Address - Phone:708-430-4440
Mailing Address - Fax:
Practice Address - Street 1:8704 RIDGELAND AVE
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-1068
Practice Address - Country:US
Practice Address - Phone:708-430-4440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-25
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0180021741223S0112X
390200000X
IL0190334321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program