Provider Demographics
NPI:1396830808
Name:TAHIR, EJAZ U (DDS, MS)
Entity Type:Individual
Prefix:
First Name:EJAZ
Middle Name:U
Last Name:TAHIR
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1 SHENANDOAH CT
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-1462
Mailing Address - Country:US
Mailing Address - Phone:630-378-4704
Mailing Address - Fax:630-378-4760
Practice Address - Street 1:2140 WESLEY AVE
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-1858
Practice Address - Country:US
Practice Address - Phone:708-484-8686
Practice Address - Fax:708-484-8687
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics