MEDICARE: MOHAMMED K QAISI DMD, MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	019.030516	IL
2	204E00000X	Oral & Maxillofacial Surgery (D.M.D.)	036.139464	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1679783088
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MOHAMMED K QAISI DMD, MD

Provider Business Mailing Address
First Line	:	1969 W OGDEN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60612-3765
Country	:	US
Telephone Number	:	128-645-1633
Fax Number	:

Provider Business Practice Location Address
First Line	:	1969 W OGDEN AVE # CLINICD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60612-3765
Country	:	US
Telephone Number	:	128-645-1633
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/23/2007
Last Update Date	:	04/28/2021

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