Provider Demographics
NPI:1043524911
Name:HUSSAN, SAMY (DDS)
Entity Type:Individual
Prefix:DR
First Name:SAMY
Middle Name:
Last Name:HUSSAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 W. ERIE ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610
Mailing Address - Country:US
Mailing Address - Phone:312-274-0308
Mailing Address - Fax:312-944-9499
Practice Address - Street 1:6560 W FULLERTON AVE
Practice Address - Street 2:# O
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60707
Practice Address - Country:US
Practice Address - Phone:773-385-6700
Practice Address - Fax:773-385-6767
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-03
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019028437122300000X
CA59305122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist