Provider Demographics
NPI:1427435056
Name:MCLEAN DENTAL CLINIC, P.C.
Entity type:Organization
Organization Name:MCLEAN DENTAL CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MUMTAZ
Authorized Official - Middle Name:
Authorized Official - Last Name:SIDDIQUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-943-7709
Mailing Address - Street 1:400 N DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:HARVARD
Mailing Address - State:IL
Mailing Address - Zip Code:60033-3061
Mailing Address - Country:US
Mailing Address - Phone:815-943-7709
Mailing Address - Fax:815-943-2009
Practice Address - Street 1:400 N DIVISION ST
Practice Address - Street 2:
Practice Address - City:HARVARD
Practice Address - State:IL
Practice Address - Zip Code:60033-3061
Practice Address - Country:US
Practice Address - Phone:815-943-7709
Practice Address - Fax:815-943-2009
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MCLEAN DENTAL, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-05-04
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019022632261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019022632Medicaid