=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689059297
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMER ATASSI D.M.D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2015
-----------------------------------------------------
Last Update Date | 01/13/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6224 S ELM ST
-----------------------------------------------------
City | BURR RIDGE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60527-5228
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-290-9506
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20 BLUE GRASS CT
-----------------------------------------------------
City | OAK BROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60523-2613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-800-3041
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | 019030111
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | 2901017148
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------