Healthcare Provider Details

I. General information

NPI: 1972328995
Provider Name (Legal Business Name): ALI ABUSHAMAT DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2024
Last Update Date: 07/07/2025
Certification Date: 06/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2937 IL-178 SUITE 2
NORTH UTICA IL
61373
US

IV. Provider business mailing address

2937 IL-178 SUITE 2
NORTH UTICA IL
61373
US

V. Phone/Fax

Practice location:
  • Phone: 815-993-3101
  • Fax:
Mailing address:
  • Phone: 815-993-3101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019036179
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: