Provider Demographics
NPI:1467160150
Name:AZZAM, MUDAR (DDS)
Entity Type:Individual
Prefix:DR
First Name:MUDAR
Middle Name:
Last Name:AZZAM
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 1:747 N WABASH AVE APT 1207
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2267
Mailing Address - Country:US
Mailing Address - Phone:313-699-0374
Mailing Address - Fax:
Practice Address - Street 1:939 W NORTH AVE STE 890
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-8683
Practice Address - Country:US
Practice Address - Phone:312-642-3370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-10
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.033999122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist