Provider Demographics
NPI:1790327336
Name:ELKHADRA, ABDULA (DMD)
Entity Type:Individual
Prefix:DR
First Name:ABDULA
Middle Name:
Last Name:ELKHADRA
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 1:8691 CROWN CT
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-7130
Mailing Address - Country:US
Mailing Address - Phone:630-880-6071
Mailing Address - Fax:
Practice Address - Street 1:4849 W BELMONT AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-4330
Practice Address - Country:US
Practice Address - Phone:773-930-4943
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-15
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12013271A122300000X
WI1002223-15122300000X
IL019.032394122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist