Provider Demographics
NPI:1215436498
Name:SALAH, MOATAZ
Entity type:Individual
Prefix:
First Name:MOATAZ
Middle Name:
Last Name:SALAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MOATAZ
Other - Middle Name:
Other - Last Name:MOHAMED
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5836 S HARLEM AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:SUMMIT
Mailing Address - State:IL
Mailing Address - Zip Code:60501-1407
Mailing Address - Country:US
Mailing Address - Phone:708-215-4000
Mailing Address - Fax:
Practice Address - Street 1:5540 WALNUT AVE APT 14C
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-4127
Practice Address - Country:US
Practice Address - Phone:661-916-9850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-02
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019031474122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019.031474Medicaid