Provider Demographics
NPI:1992048912
Name:SECURE DENTAL II
Entity type:Organization
Organization Name:SECURE DENTAL II
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:NAZISH
Authorized Official - Middle Name:HASAN
Authorized Official - Last Name:JAFRI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:815-708-2762
Mailing Address - Street 1:1695 DIVINE DR
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-5417
Mailing Address - Country:US
Mailing Address - Phone:815-708-2762
Mailing Address - Fax:
Practice Address - Street 1:4601 16TH ST
Practice Address - Street 2:UNIT 12
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-7000
Practice Address - Country:US
Practice Address - Phone:815-708-2762
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-27
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190288071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty