MEDICARE: FREEPORT FAMILY DENTAL, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1013667534
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FREEPORT FAMILY DENTAL, LLC

Provider Business Mailing Address
First Line	:	981 W SOUTH ST
Second Line	:
City	:	FREEPORT
State	:	IL
Zip	:	61032-6778
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	981 W SOUTH ST
Second Line	:
City	:	FREEPORT
State	:	IL
Zip	:	61032-6778
Country	:	US
Telephone Number	:	815-235-5174
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	DR. MAHMOUD SALAMEH
Credential	:
Telephone Number	:	708-543-0089

Provider Enumeration Date	:	03/27/2022
Last Update Date	:	03/27/2022

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Directions to “FREEPORT FAMILY DENTAL, LLC ” Practice Location

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