Healthcare Provider Details

I. General information

NPI: 1447363643
Provider Name (Legal Business Name): ILYAS M AHMED DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 09/15/2025
Certification Date: 09/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 W NORTH AVE
NORTHLAKE IL
60164-2306
US

IV. Provider business mailing address

75 W NORTH AVE STE 400
NORTHLAKE IL
60164-2314
US

V. Phone/Fax

Practice location:
  • Phone: 708-562-5100
  • Fax: 708-562-5112
Mailing address:
  • Phone: 708-562-5100
  • Fax: 708-562-5112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number019026721
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019026721
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: