Healthcare Provider Details

I. General information

NPI: 1285124792
Provider Name (Legal Business Name): MOHAMMED H ELNAGAR DDS,MSC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2018
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 S PAULINA ST RM 131
CHICAGO IL
60612-7210
US

IV. Provider business mailing address

801 S PAULINA ST RM 131
CHICAGO IL
60612-7210
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-7505
  • Fax: 312-996-0873
Mailing address:
  • Phone: 312-996-0873
  • Fax: 312-996-0873

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number136.000213
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: