Healthcare Provider Details

I. General information

NPI: 1265285167
Provider Name (Legal Business Name): FULLERTON DENTAL ISLAND LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2024
Last Update Date: 04/09/2024
Certification Date: 04/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5205 W FULLERTON AVE
CHICAGO IL
60639-1401
US

IV. Provider business mailing address

5836 W 100TH PL
OAK LAWN IL
60453-3774
US

V. Phone/Fax

Practice location:
  • Phone: 312-709-1722
  • Fax:
Mailing address:
  • Phone: 312-709-1722
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: WISAM MUSA
Title or Position: OWNER
Credential: DDS
Phone: 312-709-1722