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General NPI Number Information
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NPI Number | 1891031647
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Entity Type | Organization
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Legal Business Name | CHICAGO ORAL MEDICINE
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Dates
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Enumeration Date | 12/26/2012
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Last Update Date | 12/26/2012
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Provider Practice Location Address
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Address Line | 10763 163RD PLACE
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City | ORLAND PARK
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State | IL
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Zip | 60467
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Country | US
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Telephone | 517-214-4034
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Fax |
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Provider Business Mailing Address
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Address Line | 10763 163RD PL
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City | ORLAND PARK
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State | IL
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Zip | 60467-8861
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Country | US
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Telephone | 517-214-4034
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Fax |
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Authorized Official
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Title or Position | PRESEIDENT
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Name | BASSAM ALI ISSA
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Credential | DDS
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Telephone | 517-214-4034
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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 | 019029193
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License Number State | IL
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