Provider Demographics
NPI:1972766186
Name:OBAISI, REEM MUTIAH (DDS)
Entity Type:Individual
Prefix:
First Name:REEM
Middle Name:MUTIAH
Last Name:OBAISI
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 1:3334 W PETERSON AVE
Mailing Address - Street 2:LOWER LEVEL
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-3505
Mailing Address - Country:US
Mailing Address - Phone:773-588-9200
Mailing Address - Fax:773-588-9201
Practice Address - Street 1:3334 W PETERSON AVE
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-3505
Practice Address - Country:US
Practice Address - Phone:773-588-9200
Practice Address - Fax:773-588-9201
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-08
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190276191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1972766186Medicaid