Provider Demographics
NPI:1053054304
Name:SALEH, DEAYA (DMD)
Entity Type:Individual
Prefix:
First Name:DEAYA
Middle Name:
Last Name:SALEH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7042 BREMENTOWNE RD
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-1639
Mailing Address - Country:US
Mailing Address - Phone:708-691-2723
Mailing Address - Fax:
Practice Address - Street 1:2215 OAK PARK AVE
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-2220
Practice Address - Country:US
Practice Address - Phone:708-218-9642
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-14
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL019.0336451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program