Provider Demographics
NPI:1427772698
Name:U.S. DENTAL GROUP LLC
Entity type:Organization
Organization Name:U.S. DENTAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:VICKEN
Authorized Official - Middle Name:
Authorized Official - Last Name:ISHKHANIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:184-741-4357
Mailing Address - Street 1:1447 LEE ST
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60018-1516
Mailing Address - Country:US
Mailing Address - Phone:847-294-0404
Mailing Address - Fax:
Practice Address - Street 1:1447 LEE ST
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60018-1516
Practice Address - Country:US
Practice Address - Phone:847-294-0404
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-30
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1004451Medicaid