Healthcare Provider Details

I. General information

NPI: 1144283706
Provider Name (Legal Business Name): SALMAAN UMAR-POOTHAWALA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 03/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1624 WEST MONTROSE AVE
CHICAGO IL
60613
US

IV. Provider business mailing address

1624 WEST MONTROSE AVE
CHICAGO IL
60613
US

V. Phone/Fax

Practice location:
  • Phone: 773-275-5600
  • Fax: 773-275-5868
Mailing address:
  • Phone: 773-275-5600
  • Fax: 773-275-5868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019026329
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: