Provider Demographics
NPI:1124709183
Name:MANZOOR, SUBHAN (DDS)
Entity type:Individual
Prefix:
First Name:SUBHAN
Middle Name:
Last Name:MANZOOR
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 PAMELA DR
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-1373
Mailing Address - Country:US
Mailing Address - Phone:630-209-5610
Mailing Address - Fax:
Practice Address - Street 1:8021 W 79TH ST
Practice Address - Street 2:
Practice Address - City:JUSTICE
Practice Address - State:IL
Practice Address - Zip Code:60458-1607
Practice Address - Country:US
Practice Address - Phone:708-634-0843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-31
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6001302-15122300000X
IL019.034681122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist