=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578139598
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DR. ALI AMRA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2021
-----------------------------------------------------
Last Update Date | 06/01/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16473 W 159TH ST
-----------------------------------------------------
City | LOCKPORT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60441-7961
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-369-6324
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6 W STONEBRIDGE CT UNIT A
-----------------------------------------------------
City | PALOS HILLS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60465-4218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-369-6324
-----------------------------------------------------
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 | 019.033101
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------