Healthcare Provider Details

I. General information

NPI: 1750105748
Provider Name (Legal Business Name): ILLINOIS ORAL SURGERY & IMPLANT CENTER OF CHANNAHON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2024
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27025 W EAMES ST
CHANNAHON IL
60410-5619
US

IV. Provider business mailing address

27025 W EAMES ST
CHANNAHON IL
60410-5619
US

V. Phone/Fax

Practice location:
  • Phone: 630-355-9449
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. MOHAMMED K ALMANDALAWI
Title or Position: OWNER
Credential: DMD, BDS
Phone: 630-355-9449