Provider Demographics
NPI:1346090362
Name:DHALIWAL, PREET KANWAL
Entity type:Individual
Prefix:
First Name:PREET KANWAL
Middle Name:
Last Name:DHALIWAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 GREYSTEM CIR APT 305
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-9324
Mailing Address - Country:US
Mailing Address - Phone:952-999-0965
Mailing Address - Fax:
Practice Address - Street 1:350 N CLARK ST STE 600
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-4782
Practice Address - Country:US
Practice Address - Phone:312-274-4524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-25
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL019.0352801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program