Provider Demographics
NPI:1255321170
Name:MUSTAFA, SHAFAQ RAAFAT (DDS)
Entity type:Individual
Prefix:
First Name:SHAFAQ
Middle Name:RAAFAT
Last Name:MUSTAFA
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 1:16111 LA SALLE ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473-2064
Mailing Address - Country:US
Mailing Address - Phone:708-339-9999
Mailing Address - Fax:708-339-0009
Practice Address - Street 1:16111 LA SALLE ST
Practice Address - Street 2:
Practice Address - City:SOUTH HOLLAND
Practice Address - State:IL
Practice Address - Zip Code:60473-2064
Practice Address - Country:US
Practice Address - Phone:708-339-9999
Practice Address - Fax:708-339-0009
Is Sole Proprietor?:No
Enumeration Date:2005-10-22
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9178436Medicaid