Provider Demographics
NPI:1508590415
Name:TOOTHTOWN PLLC
Entity Type:Organization
Organization Name:TOOTHTOWN PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YUSUF
Authorized Official - Middle Name:
Authorized Official - Last Name:FAHMY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:630-352-1547
Mailing Address - Street 1:1042 N YALE AVE
Mailing Address - Street 2:
Mailing Address - City:VILLA PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60181-1146
Mailing Address - Country:US
Mailing Address - Phone:630-352-1547
Mailing Address - Fax:
Practice Address - Street 1:303 W LAKE ST STE 300
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:IL
Practice Address - Zip Code:60101-2564
Practice Address - Country:US
Practice Address - Phone:630-352-1547
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-15
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019030794Medicaid