Provider Demographics
NPI:1174994479
Name:CALUMET PARK DENTAL INC.
Entity type:Organization
Organization Name:CALUMET PARK DENTAL INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHAMEEMA
Authorized Official - Middle Name:
Authorized Official - Last Name:ESSOF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-890-3123
Mailing Address - Street 1:PO BOX 179
Mailing Address - Street 2:
Mailing Address - City:BLUE ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60406-0179
Mailing Address - Country:US
Mailing Address - Phone:708-597-3131
Mailing Address - Fax:708-597-1898
Practice Address - Street 1:1328 W 127TH ST
Practice Address - Street 2:
Practice Address - City:CALUMET PARK
Practice Address - State:IL
Practice Address - Zip Code:60827-6129
Practice Address - Country:US
Practice Address - Phone:708-597-3131
Practice Address - Fax:798-597-1898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-13
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019023113122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty