Provider Demographics
NPI:1972025112
Name:GHAZAL, NILOUFAR (DMD)
Entity Type:Individual
Prefix:
First Name:NILOUFAR
Middle Name:
Last Name:GHAZAL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16620 W 159TH ST
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:IL
Mailing Address - Zip Code:60441-8012
Mailing Address - Country:US
Mailing Address - Phone:815-552-2360
Mailing Address - Fax:815-552-2963
Practice Address - Street 1:16620 W 159TH ST
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:IL
Practice Address - Zip Code:60441-8012
Practice Address - Country:US
Practice Address - Phone:815-552-2360
Practice Address - Fax:815-552-2963
Is Sole Proprietor?:No
Enumeration Date:2017-07-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019031246122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist