Provider Demographics
NPI:1013647296
Name:AL GAILANI, MAHMOOD HASSAN ALI HAIDER
Entity Type:Individual
Prefix:
First Name:MAHMOOD
Middle Name:HASSAN ALI HAIDER
Last Name:AL GAILANI
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 1:2760 S HIGHLAND AVE APT 427
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-5433
Mailing Address - Country:US
Mailing Address - Phone:619-246-8237
Mailing Address - Fax:
Practice Address - Street 1:6301 CERMAK RD STE B
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-2368
Practice Address - Country:US
Practice Address - Phone:708-956-7516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-12
Last Update Date:2024-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.033637122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist