Healthcare Provider Details

I. General information

NPI: 1750584546
Provider Name (Legal Business Name): HASAN FAWWAZ OTHMAN DDS, MS, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2340 S HIGHLAND AVE SUITE 310
LOMBARD IL
60148-5371
US

IV. Provider business mailing address

2340 S HIGHLAND AVE SUITE 310
LOMBARD IL
60148-5371
US

V. Phone/Fax

Practice location:
  • Phone: 630-424-9070
  • Fax: 630-424-9077
Mailing address:
  • Phone: 630-424-9070
  • Fax: 630-424-9077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: