Provider Demographics
NPI:1225220726
Name:MUSSARI, PHILIP MARK (DDS)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:MARK
Last Name:MUSSARI
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 1:5042 PRATT AVE
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60077-3513
Mailing Address - Country:US
Mailing Address - Phone:847-983-0748
Mailing Address - Fax:
Practice Address - Street 1:4725 W FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-1817
Practice Address - Country:US
Practice Address - Phone:773-252-4240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-17
Last Update Date:2007-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019021820122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019021820OtherDENTAL LICENCE NUMBER