MEDICARE: DR. MAMOON SALAMAH MOHAMAD DMD

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	390200000X	Student in an Organized Health Care Education/Training Program
2	1223G0001X	General Practice Dentistry	019.035060	IL

General Provider Information

NPI Number	:	1053167999
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MAMOON SALAMAH MOHAMAD DMD

Provider Business Mailing Address
First Line	:	4305 N OLCOTT AVE
Second Line	:
City	:	NORRIDGE
State	:	IL
Zip	:	60706-1138
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3138 N NARRAGANSETT AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60634-4919
Country	:	US
Telephone Number	:	773-745-6410
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/30/2024
Last Update Date	:	06/26/2024

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