Basic Information
| Provider Information | |||||||||
| NPI: | 1043524911 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HUSSAN | ||||||||
| FirstName: | SAMY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 430 W. ERIE ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3122740308 | ||||||||
| FaxNumber: | 3129449499 | ||||||||
| Practice Location | |||||||||
| Address1: | 6560 W FULLERTON AVE | ||||||||
| Address2: | # O | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7733856700 | ||||||||
| FaxNumber: | 7733856767 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2010 | ||||||||
| LastUpdateDate: | 08/03/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 019028437 | IL | Y | Dental Providers | Dentist | 122300000X | 59305 | CA | N | Dental Providers | Dentist |
No ID Information.