Provider Demographics
NPI:1588004246
Name:GOLAM, ISRAA (DDS)
Entity Type:Individual
Prefix:
First Name:ISRAA
Middle Name:
Last Name:GOLAM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 LOG TRAIL DR
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-3771
Mailing Address - Country:US
Mailing Address - Phone:773-516-3739
Mailing Address - Fax:
Practice Address - Street 1:9378 OLIVE BLVD
Practice Address - Street 2:SUITE.1LL
Practice Address - City:OLIVETTE
Practice Address - State:MO
Practice Address - Zip Code:63132-3215
Practice Address - Country:US
Practice Address - Phone:314-872-3930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-26
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.029464122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist