Healthcare Provider Details

I. General information

NPI: 1821652736
Provider Name (Legal Business Name): ORAL AND MAXILLOFICIAL HEAD AND NECK ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2019
Last Update Date: 04/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 WEST WELLINGTON AVENUE ATTENTION: MOHAMMED QAISI, MD., DMD.
CHICAGO IL
60657-5123
US

IV. Provider business mailing address

PO BOX 734471
CHICAGO IL
60673-4471
US

V. Phone/Fax

Practice location:
  • Phone: 847-676-0091
  • Fax: 847-676-2374
Mailing address:
  • Phone: 847-676-0091
  • Fax: 847-676-2374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State

VIII. Authorized Official

Name: DR. MOHAMMED QAISI
Title or Position: MEMBER
Credential: MD DMD
Phone: 318-547-2825