Healthcare Provider Details

I. General information

NPI: 1932748977
Provider Name (Legal Business Name): MAHMOUD MONA DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2019
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
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: 708-580-0100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number021.003327
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDN24642
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number019.035017
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN24642
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: