Provider Demographics
NPI:1417392457
Name:OBAISI, NOOR AMINAH (DDS)
Entity Type:Individual
Prefix:
First Name:NOOR
Middle Name:AMINAH
Last Name:OBAISI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 E. HURON ST.
Mailing Address - Street 2:APT 1703
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611
Mailing Address - Country:US
Mailing Address - Phone:217-314-0033
Mailing Address - Fax:
Practice Address - Street 1:30 E HURON ST
Practice Address - Street 2:APT 1703
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2766
Practice Address - Country:US
Practice Address - Phone:217-314-0033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-03
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019028304122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1417392457Medicaid