Provider Demographics
NPI:1942212782
Name:AMAYUN, MARVIN (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:
Last Name:AMAYUN
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 1:1100 NERGE RD
Mailing Address - Street 2:STE 209
Mailing Address - City:ELK GROVE VILLAGE
Mailing Address - State:IL
Mailing Address - Zip Code:60007-3240
Mailing Address - Country:US
Mailing Address - Phone:847-891-6600
Mailing Address - Fax:
Practice Address - Street 1:1100 NERGE RD
Practice Address - Street 2:STE 209
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007-3240
Practice Address - Country:US
Practice Address - Phone:847-891-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2012-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0261021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019026102Medicaid