Provider Demographics
NPI:1689102667
Name:ALSAMARRAIE, MOHAMMED M (DMD)
Entity Type:Individual
Prefix:
First Name:MOHAMMED
Middle Name:M
Last Name:ALSAMARRAIE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 W GRENSHAW ST UNIT 1W
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4816
Mailing Address - Country:US
Mailing Address - Phone:703-474-5757
Mailing Address - Fax:
Practice Address - Street 1:1300 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-3127
Practice Address - Country:US
Practice Address - Phone:414-377-3808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-02
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-031096122300000X
WI1001540-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1689102667Medicaid