Provider Demographics
NPI:1811520372
Name:GHISHAN, TALA (DDS)
Entity type:Individual
Prefix:
First Name:TALA
Middle Name:
Last Name:GHISHAN
Suffix:
Gender:
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 E ERIE ST APT 3609
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3159
Mailing Address - Country:US
Mailing Address - Phone:404-395-0455
Mailing Address - Fax:
Practice Address - Street 1:801 S PAULINA ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-7210
Practice Address - Country:US
Practice Address - Phone:312-996-7555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-12
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0338591223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics