=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538430590
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WAEIL ELMISALATI DDS, MMEDSC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2012
-----------------------------------------------------
Last Update Date | 10/24/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2335 W FULLERTON AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60647-3225
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-953-0266
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 415 HOWARD ST APT 1612
-----------------------------------------------------
City | EVANSTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60202-4056
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-953-0266
-----------------------------------------------------
Fax | 617-432-4258
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 019.030426
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | 021002903
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------