Provider Demographics
NPI:1831110006
Name:SOURI, GHASSAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:GHASSAN
Middle Name:
Last Name:SOURI
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 1:2750 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-5247
Mailing Address - Country:US
Mailing Address - Phone:312-432-4541
Mailing Address - Fax:773-342-3204
Practice Address - Street 1:2750 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-5247
Practice Address - Country:US
Practice Address - Phone:312-432-4541
Practice Address - Fax:773-342-3204
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-22
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190220671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice