Provider Demographics
NPI:1306837349
Name:AHMED, AHSAN (DDSMS)
Entity type:Individual
Prefix:
First Name:AHSAN
Middle Name:
Last Name:AHMED
Suffix:
Gender:M
Credentials:DDSMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 SAINT GERMAIN PL
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60175-4606
Mailing Address - Country:US
Mailing Address - Phone:630-587-4470
Mailing Address - Fax:630-513-1905
Practice Address - Street 1:32 SAINT GERMAIN PL
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60175-4606
Practice Address - Country:US
Practice Address - Phone:630-587-4470
Practice Address - Fax:630-513-1905
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190251141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1005317Medicaid