Provider Demographics
NPI:1134568868
Name:ALI, BASSAM S (DDS)
Entity type:Individual
Prefix:DR
First Name:BASSAM
Middle Name:S
Last Name:ALI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2430 SALINA ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48120-1549
Mailing Address - Country:US
Mailing Address - Phone:313-615-1007
Mailing Address - Fax:
Practice Address - Street 1:350 N CLARK ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-4712
Practice Address - Country:US
Practice Address - Phone:312-274-4524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-16
Last Update Date:2013-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901020984122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist