Provider Demographics
NPI:1518533553
Name:MASSAD, AHMED
Entity Type:Individual
Prefix:
First Name:AHMED
Middle Name:
Last Name:MASSAD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1063 W TAYLOR ST APT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-4973
Mailing Address - Country:US
Mailing Address - Phone:708-916-2406
Mailing Address - Fax:
Practice Address - Street 1:3939 W FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-2243
Practice Address - Country:US
Practice Address - Phone:708-916-2406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-01
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.033104122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist