Provider Demographics
NPI:1043720907
Name:CHICAGO DENTAL BOUTIQUES
Entity type:Organization
Organization Name:CHICAGO DENTAL BOUTIQUES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROHI
Authorized Official - Middle Name:
Authorized Official - Last Name:ATASSI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:312-868-0301
Mailing Address - Street 1:333 E BENTON PL STE 202
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-7411
Mailing Address - Country:US
Mailing Address - Phone:312-868-0301
Mailing Address - Fax:
Practice Address - Street 1:333 E BENTON PL STE 202
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-7411
Practice Address - Country:US
Practice Address - Phone:312-868-0301
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-05
Last Update Date:2017-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019030540122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty