Provider Demographics
NPI:1053753699
Name:PARK WEST FAMILY DENTISTRY, PC
Entity type:Organization
Organization Name:PARK WEST FAMILY DENTISTRY, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FARIHA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIDDIQUI IMAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-880-6054
Mailing Address - Street 1:4909 W DIVISION ST
Mailing Address - Street 2:#409
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60651-3161
Mailing Address - Country:US
Mailing Address - Phone:773-378-4608
Mailing Address - Fax:
Practice Address - Street 1:4909 W DIVISION ST
Practice Address - Street 2:#409
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60651-3161
Practice Address - Country:US
Practice Address - Phone:773-378-4608
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PARK WEST FAMILY DENTISTRY, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-07-24
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019027922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty