Provider Demographics
NPI:1003322520
Name:ALI, AMJAD
Entity Type:Individual
Prefix:
First Name:AMJAD
Middle Name:
Last Name:ALI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 N CLARK ST STE 600
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-4782
Mailing Address - Country:US
Mailing Address - Phone:281-785-5300
Mailing Address - Fax:
Practice Address - Street 1:4804 W CHERRYWOOD CT
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79707-2601
Practice Address - Country:US
Practice Address - Phone:281-785-5300
Practice Address - Fax:281-785-5300
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-20
Last Update Date:2018-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL019.0314851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program