Provider Demographics
NPI:1669218798
Name:SAHOURI, ISSA
Entity type:Individual
Prefix:
First Name:ISSA
Middle Name:
Last Name:SAHOURI
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 1:10214 MULBERRY LN APT B
Mailing Address - Street 2:
Mailing Address - City:BRIDGEVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60455-6017
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:141 E PERSHING RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-3213
Practice Address - Country:US
Practice Address - Phone:217-877-6559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-08
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.035317122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty