Provider Demographics
NPI:1366613671
Name:HYDE PARK DENTAL PROFILE
Entity type:Organization
Organization Name:HYDE PARK DENTAL PROFILE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:D.D.S
Authorized Official - Prefix:
Authorized Official - First Name:AMNEH
Authorized Official - Middle Name:
Authorized Official - Last Name:ARNOUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-752-5677
Mailing Address - Street 1:1634 E 53RD ST
Mailing Address - Street 2:SUITE 101&102
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-4384
Mailing Address - Country:US
Mailing Address - Phone:773-752-5677
Mailing Address - Fax:773-752-6029
Practice Address - Street 1:1634 E 53RD ST
Practice Address - Street 2:SUITE 101&102
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-4384
Practice Address - Country:US
Practice Address - Phone:773-752-5677
Practice Address - Fax:773-752-6029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-13
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty