Healthcare Provider Details

I. General information

NPI: 1043669419
Provider Name (Legal Business Name): MUSTAFA OBAIDI DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2016
Last Update Date: 05/10/2021
Certification Date: 05/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3420 W ELM ST
MCHENRY IL
60050-4433
US

IV. Provider business mailing address

3420 W ELM ST
MCHENRY IL
60050-4433
US

V. Phone/Fax

Practice location:
  • Phone: 815-344-0453
  • Fax:
Mailing address:
  • Phone: 815-344-0453
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019030653
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2901021942
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: