Provider Demographics
NPI:1033782271
Name:EISHO, MAZEN
Entity Type:Individual
Prefix:MRS
First Name:MAZEN
Middle Name:
Last Name:EISHO
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 1:722 RAND GROVE LN APT 2A
Mailing Address - Street 2:
Mailing Address - City:PALATINE
Mailing Address - State:IL
Mailing Address - Zip Code:60074-1148
Mailing Address - Country:US
Mailing Address - Phone:773-952-9109
Mailing Address - Fax:
Practice Address - Street 1:722 RAND GROVE LN APT 2A
Practice Address - Street 2:
Practice Address - City:PALATINE
Practice Address - State:IL
Practice Address - Zip Code:60074-1148
Practice Address - Country:US
Practice Address - Phone:773-952-9109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-23
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019033326122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist