=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902018948
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REEM SABBAGH DDS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2007
-----------------------------------------------------
Last Update Date | 08/09/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 811 W WELLINGTON AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60657-5123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-871-4964
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 811 W WELLINGTON AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60657-5123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | REEM SABBAGH
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 773-871-4964
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 019025390
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------