MEDICARE: DR. MOHAMMAD DOULEH 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	122300000X	Dentist	019.034461	IL

General Provider Information

NPI Number	:	1477232023
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MOHAMMAD DOULEH DMD

Provider Business Mailing Address
First Line	:	2643 N 74TH CT
Second Line	:
City	:	ELMWOOD PARK
State	:	IL
Zip	:	60707-1924
Country	:	US
Telephone Number	:	773-809-0123
Fax Number	:

Provider Business Practice Location Address
First Line	:	2727 N OAKLAND AVE
Second Line	:
City	:	DECATUR
State	:	IL
Zip	:	62526-1586
Country	:	US
Telephone Number	:	217-875-4505
Fax Number	:

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

Provider Enumeration Date	:	07/12/2023
Last Update Date	:	07/12/2023

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