Provider Demographics
NPI:1457101545
Name:SHIRAZI, SAJJAD (DDS, PHD)
Entity type:Individual
Prefix:
First Name:SAJJAD
Middle Name:
Last Name:SHIRAZI
Suffix:
Gender:M
Credentials:DDS, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 W WELLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-5123
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:811 W WELLINGTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5123
Practice Address - Country:US
Practice Address - Phone:773-871-6138
Practice Address - Fax:773-871-6353
Is Sole Proprietor?:No
Enumeration Date:2024-03-25
Last Update Date:2024-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL018.0022691223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery