Provider Demographics
NPI:1710373550
Name:LISLE FAMILY DENTAL INC
Entity type:Organization
Organization Name:LISLE FAMILY DENTAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FARIHA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIDDIQUI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-880-6054
Mailing Address - Street 1:3033 OGDEN AVE
Mailing Address - Street 2:SUITE 114
Mailing Address - City:LISLE
Mailing Address - State:IL
Mailing Address - Zip Code:60532-1673
Mailing Address - Country:US
Mailing Address - Phone:630-961-1030
Mailing Address - Fax:630-961-0223
Practice Address - Street 1:3033 OGDEN AVE
Practice Address - Street 2:SUITE 114
Practice Address - City:LISLE
Practice Address - State:IL
Practice Address - Zip Code:60532-1673
Practice Address - Country:US
Practice Address - Phone:630-961-1030
Practice Address - Fax:630-961-0223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-08
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019027922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty