Healthcare Provider Details

I. General information

NPI: 1871096883
Provider Name (Legal Business Name): SAMIR SABIR HASSAN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2018
Last Update Date: 01/11/2022
Certification Date: 01/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15800 S HARLEM AVE
ORLAND PARK IL
60462-5212
US

IV. Provider business mailing address

360 E SOUTH WATER ST APT 3505
CHICAGO IL
60601-4146
US

V. Phone/Fax

Practice location:
  • Phone: 708-658-3356
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019.031668
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number019.031668
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: