Provider Demographics
NPI:1891031647
Name:CHICAGO ORAL MEDICINE
Entity Type:Organization
Organization Name:CHICAGO ORAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESEIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BASSAM
Authorized Official - Middle Name:ALI
Authorized Official - Last Name:ISSA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:517-214-4034
Mailing Address - Street 1:10763 163RD PL
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-8861
Mailing Address - Country:US
Mailing Address - Phone:517-214-4034
Mailing Address - Fax:
Practice Address - Street 1:10763 163RD PLACE
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60467
Practice Address - Country:US
Practice Address - Phone:517-214-4034
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-26
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019029193122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty