=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063060275
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MALIK MUHAMMAD ZEESHANSHER KHAN DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2019
-----------------------------------------------------
Last Update Date | 08/30/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2702 W TOUHY AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60645-3008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-338-7799
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 233 E WACKER DR APT 3902
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60601-5115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-634-8934
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 019.032379
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------