Provider Demographics
NPI:1588288906
Name:KHAN, USAMAH MUHAMMAD (DMD)
Entity type:Individual
Prefix:
First Name:USAMAH
Middle Name:MUHAMMAD
Last Name:KHAN
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 1:515 N GRACE ST
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-1855
Mailing Address - Country:US
Mailing Address - Phone:630-873-9058
Mailing Address - Fax:
Practice Address - Street 1:4434A W FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-1932
Practice Address - Country:US
Practice Address - Phone:708-562-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-01
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0325631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice