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General NPI Number Information
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NPI Number | 1750105748
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Entity Type | Organization
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Legal Business Name | ILLINOIS ORAL SURGERY & IMPLANT CENTER OF CHANNAHON
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Dates
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Enumeration Date | 11/14/2024
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Last Update Date | 11/14/2024
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Provider Practice Location Address
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Address Line | 27025 W EAMES ST
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City | CHANNAHON
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State | IL
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Zip | 60410-5619
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Country | US
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Telephone | 630-355-9449
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Fax |
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Provider Business Mailing Address
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Address Line | 27025 W EAMES ST
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City | CHANNAHON
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State | IL
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Zip | 60410-5619
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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 | OWNER
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Name | DR. MOHAMMED K ALMANDALAWI
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Credential | DMD, BDS
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Telephone | 630-355-9449
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QS0112X
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Taxonomy Name | Oral and Maxillofacial Surgery Clinic/Center
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License Number |
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License Number State |
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