=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699189886
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIMA GHUNAIM D.D.S. , M.S., FACP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2014
-----------------------------------------------------
Last Update Date | 03/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 801 S PAULINA ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60612-7210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-996-2669
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 650 W BALTIMORE ST STE 1401
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21201-1510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-706-6198
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0700X
-----------------------------------------------------
Taxonomy Name | Prosthodontics
-----------------------------------------------------
License Number | 15184
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223P0700X
-----------------------------------------------------
Taxonomy Name | Prosthodontics
-----------------------------------------------------
License Number | 019033921
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------