Provider Demographics
NPI:1871942730
Name:HUB FAMILY DENTAL
Entity type:Organization
Organization Name:HUB FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAZEEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:PARDESI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:815-262-4540
Mailing Address - Street 1:409 LINCOLN HWY
Mailing Address - Street 2:
Mailing Address - City:ROCHELLE
Mailing Address - State:IL
Mailing Address - Zip Code:61068-1642
Mailing Address - Country:US
Mailing Address - Phone:815-561-6058
Mailing Address - Fax:815-524-2567
Practice Address - Street 1:409 LINCOLN HIGHWAY
Practice Address - Street 2:
Practice Address - City:ROCHELLE
Practice Address - State:IL
Practice Address - Zip Code:61068
Practice Address - Country:US
Practice Address - Phone:815-561-6058
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ENAMEL-WORKS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-06-10
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019030152122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty