Healthcare Provider Details

I. General information

NPI: 1336635051
Provider Name (Legal Business Name): AMNA ALWALIE DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2018
Last Update Date: 08/29/2026
Certification Date: 08/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

660 E ROOSEVELT RD
LOMBARD IL
60148-4776
US

IV. Provider business mailing address

660 E ROOSEVELT RD
LOMBARD IL
60148-4776
US

V. Phone/Fax

Practice location:
  • Phone: 630-627-7651
  • Fax: 630-387-9671
Mailing address:
  • Phone: 630-627-7651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number091036204
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: