Provider Demographics
NPI:1578139598
Name:AMRA, ALI
Entity Type:Individual
Prefix:DR
First Name:ALI
Middle Name:
Last Name:AMRA
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 1:6 W STONEBRIDGE CT UNIT A
Mailing Address - Street 2:
Mailing Address - City:PALOS HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60465-4218
Mailing Address - Country:US
Mailing Address - Phone:708-369-6324
Mailing Address - Fax:
Practice Address - Street 1:16473 W 159TH ST
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:IL
Practice Address - Zip Code:60441-7961
Practice Address - Country:US
Practice Address - Phone:708-369-6324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-01
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.033101122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist