Provider Demographics
NPI:1487209664
Name:DALIRI, SAM (DMD)
Entity Type:Individual
Prefix:DR
First Name:SAM
Middle Name:
Last Name:DALIRI
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 1:1604 VISA DR UNIT 3
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-2195
Mailing Address - Country:US
Mailing Address - Phone:309-585-2522
Mailing Address - Fax:
Practice Address - Street 1:1604 VISA DR
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-2195
Practice Address - Country:US
Practice Address - Phone:773-610-1041
Practice Address - Fax:815-977-7029
Is Sole Proprietor?:No
Enumeration Date:2019-08-05
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0322661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice