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General NPI Number Information
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NPI Number | 1124709183
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Entity Type | Individual
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Provider Name | SUBHAN MANZOOR DDS
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Gender | Male
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Dates
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Enumeration Date | 07/31/2023
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Last Update Date | 10/31/2023
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Provider Practice Location Address
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Address Line | 8021 W 79TH ST
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City | JUSTICE
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State | IL
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Zip | 60458-1607
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Country | US
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Telephone | 708-634-0843
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Fax |
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Provider Business Mailing Address
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Address Line | 211 PAMELA DR
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City | BOLINGBROOK
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State | IL
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Zip | 60440-1373
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Country | US
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Telephone | 630-209-5610
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 6001302-15
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019.034681
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License Number State | IL
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