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General NPI Number Information
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NPI Number | 1902279722
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Entity Type | Individual
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Provider Name | SAM TAHBAZ DDS
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Gender | Male
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Dates
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Enumeration Date | 11/02/2015
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Last Update Date | 11/02/2015
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Provider Practice Location Address
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Address Line | 1504 N WELLS STREET
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City | CHICAGO
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State | IL
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Zip | 60610
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Country | US
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Telephone | 312-573-0007
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Fax |
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Provider Business Mailing Address
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Address Line | 1504 N. WELLS STREET
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City | CHICAGO
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State | IL
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Zip | 60160
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Country | US
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Telephone | 312-573-0007
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Fax | 312-573-0002
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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 | 019-024892
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License Number State | IL
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