Provider Demographics
NPI:1689859290
Name:ATTALLA, MAMDOUH M (DDS)
Entity Type:Individual
Prefix:DR
First Name:MAMDOUH
Middle Name:M
Last Name:ATTALLA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8541 SO STONY ISLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617
Mailing Address - Country:US
Mailing Address - Phone:773-734-5013
Mailing Address - Fax:
Practice Address - Street 1:8541 SO STONY ISLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617
Practice Address - Country:US
Practice Address - Phone:773-734-5013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-02
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019 22061122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist