Provider Demographics
NPI:1902655152
Name:ALI, GHAYDA
Entity type:Individual
Prefix:MRS
First Name:GHAYDA
Middle Name:
Last Name:ALI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9011 SKYLINE DR
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-6252
Mailing Address - Country:US
Mailing Address - Phone:708-336-0174
Mailing Address - Fax:
Practice Address - Street 1:9011 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:BURR RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60527-6252
Practice Address - Country:US
Practice Address - Phone:708-336-0174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-17
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.035093122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty