Healthcare Provider Details

I. General information

NPI: 1902739063
Provider Name (Legal Business Name): NAGEEB KHALED HASAN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4614 S KEDZIE AVE
CHICAGO IL
60632-2945
US

IV. Provider business mailing address

1823 W 45TH ST
CHICAGO IL
60609-3807
US

V. Phone/Fax

Practice location:
  • Phone: 773-512-0444
  • Fax:
Mailing address:
  • Phone: 773-512-0444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019.037160
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: