MEDICARE: TAYSEER AHMED IBRAHIM

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	01925457	IL

General Provider Information

NPI Number	:	1336163484
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAYSEER AHMED IBRAHIM

Provider Business Mailing Address
First Line	:	II316 WADSWORTH ROAD
Second Line	:
City	:	BEACH PARK
State	:	IL
Zip	:	60099-3367
Country	:	US
Telephone Number	:	847-872-5530
Fax Number	:	847-872-1683

Provider Business Practice Location Address
First Line	:	11316 W WADSWORTH RD
Second Line	:
City	:	BEACH PARK
State	:	IL
Zip	:	60099-3367
Country	:	US
Telephone Number	:	847-872-5530
Fax Number	:	847-872-1683

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

Provider Enumeration Date	:	07/26/2006
Last Update Date	:	01/22/2021

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