Healthcare Provider Details

I. General information

NPI: 1275445835
Provider Name (Legal Business Name): PRIME ENDODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2026
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17047 HARLEM AVE
TINLEY PARK IL
60477-2739
US

IV. Provider business mailing address

17047 HARLEM AVE
TINLEY PARK IL
60477-2739
US

V. Phone/Fax

Practice location:
  • Phone: 708-580-0010
  • Fax:
Mailing address:
  • Phone: 708-580-0010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. MAHMOUD MONA
Title or Position: PRESIDENT
Credential: DMD
Phone: 904-738-1049