Healthcare Provider Details

I. General information

NPI: 1730898933
Provider Name (Legal Business Name): ORAL & MAXILLOFACIAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2022
Last Update Date: 11/16/2022
Certification Date: 11/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 E WASHINGTON ST STE 825
CHICAGO IL
60602-1722
US

IV. Provider business mailing address

25 E WASHINGTON ST STE 825
CHICAGO IL
60602-1722
US

V. Phone/Fax

Practice location:
  • Phone: 773-296-7645
  • Fax: 773-295-1023
Mailing address:
  • Phone: 773-296-7645
  • Fax: 773-295-1023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State

VIII. Authorized Official

Name: DR. MOHAMMED QAISI
Title or Position: OWNER
Credential: DMD, MD, FACS
Phone: 773-296-7645