Provider Demographics
NPI:1922097294
Name:AHMED, SUMRANA S (DDS)
Entity Type:Individual
Prefix:DR
First Name:SUMRANA
Middle Name:S
Last Name:AHMED
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6121 WASHINGTON ST
Mailing Address - Street 2:SUITE # 203
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-5305
Mailing Address - Country:US
Mailing Address - Phone:847-855-7000
Mailing Address - Fax:847-855-6080
Practice Address - Street 1:2680 BELVIDERE RD
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-6006
Practice Address - Country:US
Practice Address - Phone:847-360-3045
Practice Address - Fax:847-360-0597
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0262931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1005798Medicaid