Provider Demographics
NPI:1043737919
Name:SHAHABUDDIN, SYED MUHAMMAD (DDS)
Entity Type:Individual
Prefix:
First Name:SYED
Middle Name:MUHAMMAD
Last Name:SHAHABUDDIN
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 1:368 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:EAST PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61611-2036
Mailing Address - Country:US
Mailing Address - Phone:309-694-4444
Mailing Address - Fax:309-694-3361
Practice Address - Street 1:311 N BOLINGBROOK DR
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-1968
Practice Address - Country:US
Practice Address - Phone:630-914-3505
Practice Address - Fax:630-914-3508
Is Sole Proprietor?:No
Enumeration Date:2017-08-23
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019031376122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist