Healthcare Provider Details

I. General information

NPI: 1740104991
Provider Name (Legal Business Name): SARA BALOUTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

223 W JACKSON BLVD STE 1106
CHICAGO IL
60606-6900
US

IV. Provider business mailing address

17128 TEAKWOOD DR
TINLEY PARK IL
60487-5405
US

V. Phone/Fax

Practice location:
  • Phone: 312-525-8832
  • Fax:
Mailing address:
  • Phone: 708-941-0618
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019.037422
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: