Provider Demographics
NPI:1053604413
Name:TANDON, RAHUL (DMD, MD)
Entity type:Individual
Prefix:DR
First Name:RAHUL
Middle Name:
Last Name:TANDON
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:KRISHNEHA
Other - Middle Name:
Other - Last Name:PLLC
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:930 N YORK RD STE 140
Mailing Address - Street 2:
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521-8680
Mailing Address - Country:US
Mailing Address - Phone:630-655-3333
Mailing Address - Fax:
Practice Address - Street 1:930 N YORK RD STE 140
Practice Address - Street 2:
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-8680
Practice Address - Country:US
Practice Address - Phone:630-655-3333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-18
Last Update Date:2023-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL021.0030581223S0112X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7594406Medicaid