Healthcare Provider Details

I. General information

NPI: 1114908282
Provider Name (Legal Business Name): MOHAMMAD REZA EKHTERA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 10/20/2025
Certification Date: 10/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3190 N. ELSTON AVE
CHICAGO IL
60618-7129
US

IV. Provider business mailing address

3190 N. ELSTON AVE
CHICAGO IL
60618-7129
US

V. Phone/Fax

Practice location:
  • Phone: 773-564-9916
  • Fax: 872-203-9984
Mailing address:
  • Phone: 773-564-9916
  • Fax: 872-203-9984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number019025849
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019025849
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: