Basic Information
| Provider Information | |||||||||
| NPI: | 1194948794 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RADKHAN LELAND DENTAL, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1945 W WILSON AVE | ||||||||
| Address2: | SUITE 5106 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606405255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732758855 | ||||||||
| FaxNumber: | 7732758822 | ||||||||
| Practice Location | |||||||||
| Address1: | 1945 W WILSON AVE | ||||||||
| Address2: | SUITE 5106 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606405255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732758855 | ||||||||
| FaxNumber: | 7732758822 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | KHAN | ||||||||
| AuthorizedOfficialFirstName: | TIPO | ||||||||
| AuthorizedOfficialMiddleName: | AKHTAR | ||||||||
| AuthorizedOfficialTitleorPosition: | DENTIST | ||||||||
| AuthorizedOfficialTelephone: | 7732758855 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.