Healthcare Provider Details

I. General information

NPI: 1275467797
Provider Name (Legal Business Name): MOHAMED ELSADEK
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2026
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 E BIRCH ST
CANTON IL
61520-1300
US

IV. Provider business mailing address

501 W WASHINGTON ST APT 127
EAST PEORIA IL
61611-2444
US

V. Phone/Fax

Practice location:
  • Phone: 773-668-7611
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019.037088
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: