Provider Demographics
NPI:1801907886
Name:ESLAMI, AHMAD
Entity type:Individual
Prefix:
First Name:AHMAD
Middle Name:
Last Name:ESLAMI
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 1:2323 S 109TH ST
Mailing Address - Street 2:SUITE # 275
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-1909
Mailing Address - Country:US
Mailing Address - Phone:414-321-7200
Mailing Address - Fax:414-321-3232
Practice Address - Street 1:2323 S 109TH ST
Practice Address - Street 2:SUITE # 275
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-1909
Practice Address - Country:US
Practice Address - Phone:414-321-7200
Practice Address - Fax:414-321-3232
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI32181223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI391744234OtherTIN:FEDERAL TAX ID NUMBER