Provider Demographics
NPI:1548809858
Name:PA DENTAL INCORPORATED
Entity type:Organization
Organization Name:PA DENTAL INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AJITHA
Authorized Official - Middle Name:
Authorized Official - Last Name:PARUCHURI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-730-3771
Mailing Address - Street 1:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60065-0189
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:630 MILWAUKEE AVE STE 130
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60025-5655
Practice Address - Country:US
Practice Address - Phone:847-730-3771
Practice Address - Fax:847-730-3283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-03
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty