Provider Demographics
NPI:1154533180
Name:AZAD, KOUSHAN HAIDARZADEH (DMD)
Entity type:Individual
Prefix:DR
First Name:KOUSHAN
Middle Name:HAIDARZADEH
Last Name:AZAD
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 JUSTINA ST
Mailing Address - Street 2:
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521-2417
Mailing Address - Country:US
Mailing Address - Phone:630-706-0647
Mailing Address - Fax:708-652-3990
Practice Address - Street 1:2240 S CICERO AVE
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:IL
Practice Address - Zip Code:60804-2411
Practice Address - Country:US
Practice Address - Phone:706-656-2222
Practice Address - Fax:708-652-3990
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190269201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice