Healthcare Provider Details

I. General information

NPI: 1356009542
Provider Name (Legal Business Name): MAHENOOR AHMED DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2021
Last Update Date: 12/04/2021
Certification Date: 12/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1044 N MOZART ST
CHICAGO IL
60622-2789
US

IV. Provider business mailing address

903 S ASHLAND AVE APT 102
CHICAGO IL
60607-4094
US

V. Phone/Fax

Practice location:
  • Phone: 773-772-9200
  • Fax:
Mailing address:
  • Phone: 443-805-7595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019.033421
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: