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General NPI Number Information
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NPI Number | 1841078193
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Entity Type | Individual
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Provider Name | ROHAM KASHANIMOGHADDAM
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Gender | Male
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Dates
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Enumeration Date | 09/18/2023
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Last Update Date | 09/18/2023
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Provider Practice Location Address
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Address Line | 6258 S PULASKI RD
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City | CHICAGO
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State | IL
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Zip | 60629-4610
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Country | US
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Telephone | 773-777-6363
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Fax |
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Provider Business Mailing Address
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Address Line | 512 N MCCLURG CT APT 3011
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City | CHICAGO
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State | IL
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Zip | 60611-4120
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Country | US
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Telephone | 773-603-6232
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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 | 122300000X
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Taxonomy Name | Dentist
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License Number | 019.034372
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License Number State | IL
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