Healthcare Provider Details

I. General information

NPI: 1720591837
Provider Name (Legal Business Name): ALI JARRAR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2017
Last Update Date: 11/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 N DIRKSEN PKWY
SPRINGFIELD IL
62702-1407
US

IV. Provider business mailing address

6924 N ROSEMARY LN
NILES IL
60714-4459
US

V. Phone/Fax

Practice location:
  • Phone: 217-717-3293
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019031445
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.031445
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: