Provider Demographics
NPI:1588339295
Name:MUSTAFA, SUHAYB
Entity type:Individual
Prefix:
First Name:SUHAYB
Middle Name:
Last Name:MUSTAFA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 W CERMAK RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-4204
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:495 N SUGAR GROVE PKWY STE J
Practice Address - Street 2:
Practice Address - City:SUGAR GROVE
Practice Address - State:IL
Practice Address - Zip Code:60554-8020
Practice Address - Country:US
Practice Address - Phone:630-466-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-13
Last Update Date:2023-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019033375122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist