Healthcare Provider Details

I. General information

NPI: 1437773637
Provider Name (Legal Business Name): MAHMOUD SALAMEH DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2020
Last Update Date: 06/03/2020
Certification Date: 06/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2937 N STATE ROUTE 178
UTICA IL
61373
US

IV. Provider business mailing address

9318 HAWTHORNE LN
ORLAND HILLS IL
60487-7405
US

V. Phone/Fax

Practice location:
  • Phone: 815-993-3101
  • Fax:
Mailing address:
  • Phone: 773-592-0537
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.032612
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: