Provider Demographics
NPI:1588292288
Name:KOUJAN, MOHAMMAD AMIR (DDS)
Entity type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:AMIR
Last Name:KOUJAN
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 1:3454 MANOR LN APT 301
Mailing Address - Street 2:
Mailing Address - City:HOMEWOOD
Mailing Address - State:AL
Mailing Address - Zip Code:35209-5655
Mailing Address - Country:US
Mailing Address - Phone:708-573-4810
Mailing Address - Fax:
Practice Address - Street 1:1900 W 47TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60609-3833
Practice Address - Country:US
Practice Address - Phone:773-847-9004
Practice Address - Fax:773-847-9008
Is Sole Proprietor?:No
Enumeration Date:2020-03-29
Last Update Date:2020-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.032515122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist