Organization
ICO DENTAL, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. THAER AL AZZAWI DMD (OWNER)
(713) 382-8654
Entity
Organization
Contact information
Practice address
4200 W PETERSON AVE STE 136, CHICAGO, IL 60646-6052
(773) 286-5286
Mailing address
343 W WOLF POINT PLZ UNIT 1404, CHICAGO, IL 60654-0103
(713) 382-8654
Taxonomy
Speciality
Code
Description
License number
State
261QD0000X
Dental Clinic/Center
Primary
—
—
Other
Enumeration date
08/09/2022
Last updated
08/09/2022
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