Provider Demographics
NPI:1396214425
Name:SALEM, MUSERRAH SHUBLAQ (DMD)
Entity Type:Individual
Prefix:DR
First Name:MUSERRAH
Middle Name:SHUBLAQ
Last Name:SALEM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:MUSERRAH
Other - Middle Name:OSAMA
Other - Last Name:SHUBLAQ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1515 S PRAIRIE AVE UNIT 1201
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-3156
Mailing Address - Country:US
Mailing Address - Phone:708-297-6265
Mailing Address - Fax:
Practice Address - Street 1:1515 S PRAIRIE AVE UNIT 1201
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60605-3156
Practice Address - Country:US
Practice Address - Phone:708-297-6265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-19
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0317461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty