Provider Demographics
NPI:1205676939
Name:BISHAWI, KHALED BASSAM
Entity type:Individual
Prefix:
First Name:KHALED
Middle Name:BASSAM
Last Name:BISHAWI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9759 RIDGELAND AVE APT 2E
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-2790
Mailing Address - Country:US
Mailing Address - Phone:708-374-2034
Mailing Address - Fax:
Practice Address - Street 1:61 W 144TH ST
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:IL
Practice Address - Zip Code:60827-2850
Practice Address - Country:US
Practice Address - Phone:708-849-8627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-30
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0351071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty