Provider Demographics
NPI:1205365129
Name:AL MUFTI, FAHAD
Entity Type:Individual
Prefix:DR
First Name:FAHAD
Middle Name:
Last Name:AL MUFTI
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 1:901 S ASHLAND AVE APT 203
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-4082
Mailing Address - Country:US
Mailing Address - Phone:619-201-7326
Mailing Address - Fax:
Practice Address - Street 1:901 S ASHLAND AVE APT 203
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-4082
Practice Address - Country:US
Practice Address - Phone:619-201-7326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190311211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice