Healthcare Provider Details

I. General information

NPI: 1821652736
Provider Name (Legal Business Name): ORAL AND MAXILLOFICIAL HEAD AND NECK ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2019
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 W 95TH ST STE 113
OAK LAWN IL
60453-2655
US

IV. Provider business mailing address

PO BOX 734471
CHICAGO IL
60673-4471
US

V. Phone/Fax

Practice location:
  • Phone: 773-245-5253
  • Fax: 773-295-1026
Mailing address:
  • Phone: 773-245-5253
  • Fax: 773-295-1026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MOHAMMED K QAISI
Title or Position: MANAGING PARTNER
Credential: MD FACS
Phone: 318-547-2825