Provider Demographics
NPI:1508854910
Name:ABBOUD, GHASSAN I
Entity Type:Individual
Prefix:
First Name:GHASSAN
Middle Name:
Last Name:ABBOUD
Suffix:I
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 1:5333 N CLARK ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-2121
Mailing Address - Country:US
Mailing Address - Phone:773-728-5333
Mailing Address - Fax:773-728-7405
Practice Address - Street 1:5333 N CLARK ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-2121
Practice Address - Country:US
Practice Address - Phone:773-728-5333
Practice Address - Fax:773-728-7405
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0210032341223P0700X
IL019-0236161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
No1223G0001XDental ProvidersDentistGeneral Practice