Provider Demographics
NPI:1619497021
Name:AHMADIAN KHOSHE MEHR, LEILA
Entity Type:Individual
Prefix:DR
First Name:LEILA
Middle Name:
Last Name:AHMADIAN KHOSHE MEHR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 S PAULINA ST
Mailing Address - Street 2:361 DENT (MC555)
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-7210
Mailing Address - Country:US
Mailing Address - Phone:312-996-9223
Mailing Address - Fax:312-996-3535
Practice Address - Street 1:801 S PAULINA ST
Practice Address - Street 2:361 DENT (MC555)
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-7210
Practice Address - Country:US
Practice Address - Phone:312-996-9223
Practice Address - Fax:312-996-3535
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-27
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDTP6621223P0700X
IL019.0328461223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics