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General NPI Number Information
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NPI Number | 1619343688
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Entity Type | Individual
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Provider Name | TINA KHOURY DMD
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Gender | Female
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Dates
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Enumeration Date | 08/13/2015
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Last Update Date | 08/13/2020
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Provider Practice Location Address
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Address Line | 4225 TIGER LILY LN APT 404
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City | GURNEE
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State | IL
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Zip | 60031-9641
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Country | US
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Telephone | 309-360-8440
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Fax |
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Provider Business Mailing Address
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Address Line | 50 LAKEVIEW PKWY STE 120
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City | VERNON HILLS
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State | IL
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Zip | 60061-1590
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Country | US
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Telephone |
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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 | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 019.030368
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License Number State | IL
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