Individual
AITA KOOPAHI
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
4516 S DAMEN AVE, CHICAGO, IL 60609-3013
(773) 869-0200
Mailing address
350 N CLARK ST FL 6, CHICAGO, IL 60654-4712
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
019029890
IL
1223G0001X
General Practice Dentistry
019029890
IL
Other
Enumeration date
07/08/2014
Last updated
07/08/2014
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