Healthcare Provider Details

I. General information

NPI: 1306407226
Provider Name (Legal Business Name): MAYTHAM FALAH QAISI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2019
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 10TH STREET DR
MOLINE IL
61265-6885
US

IV. Provider business mailing address

4100 10TH STREET DR
MOLINE IL
61265-6885
US

V. Phone/Fax

Practice location:
  • Phone: 309-491-8197
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.037359
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDDS-09692
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: