Provider Demographics
NPI:1124860473
Name:MOHAMMED, MANSOUR MUSA (DDS)
Entity type:Individual
Prefix:
First Name:MANSOUR
Middle Name:MUSA
Last Name:MOHAMMED
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 1:14512 ALBANY AVE
Mailing Address - Street 2:
Mailing Address - City:LEMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60439-4000
Mailing Address - Country:US
Mailing Address - Phone:708-369-7458
Mailing Address - Fax:
Practice Address - Street 1:16473 W 159TH ST
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:IL
Practice Address - Zip Code:60441-7961
Practice Address - Country:US
Practice Address - Phone:815-221-4200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-08
Last Update Date:2024-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0351961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice