Provider Demographics
NPI:1114206109
Name:ABBAS, KOMAIL (DMD)
Entity Type:Individual
Prefix:DR
First Name:KOMAIL
Middle Name:
Last Name:ABBAS
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 1:135 N MANCHESTER LN
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60108-2507
Mailing Address - Country:US
Mailing Address - Phone:630-803-6875
Mailing Address - Fax:
Practice Address - Street 1:7117 GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-1450
Practice Address - Country:US
Practice Address - Phone:262-942-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-09
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.028557122300000X
WI10020481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist