Provider Demographics
NPI:1477108959
Name:SALAM, MUSTAFA (DMD)
Entity Type:Individual
Prefix:DR
First Name:MUSTAFA
Middle Name:
Last Name:SALAM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5246 FARGO AVE
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60077-3207
Mailing Address - Country:US
Mailing Address - Phone:773-787-9462
Mailing Address - Fax:
Practice Address - Street 1:2836 W DEVON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-1513
Practice Address - Country:US
Practice Address - Phone:773-787-9462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-02
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0322971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice