Healthcare Provider Details

I. General information

NPI: 1467385385
Provider Name (Legal Business Name): EBAD SYED MUQTADER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 W SPRINGFIELD AVE
CHAMPAIGN IL
61820-4817
US

IV. Provider business mailing address

264 BALMORAL CT
GLENDALE HEIGHTS IL
60139-1305
US

V. Phone/Fax

Practice location:
  • Phone: 217-356-3335
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number390200000X
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: