MEDICARE: DR. GHASSAN SOURI D.D.S.

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	019022067	IL

General Provider Information

NPI Number	:	1831110006
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GHASSAN SOURI D.D.S.

Provider Business Mailing Address
First Line	:	2750 W NORTH AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-5247
Country	:	US
Telephone Number	:	312-432-4541
Fax Number	:	773-342-3204

Provider Business Practice Location Address
First Line	:	2750 W NORTH AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-5247
Country	:	US
Telephone Number	:	312-432-4541
Fax Number	:	773-342-3204

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

Provider Enumeration Date	:	07/22/2006
Last Update Date	:	08/06/2010

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