Provider Demographics
NPI:1962702068
Name:ABBOUD, ABDALLAH
Entity type:Individual
Prefix:
First Name:ABDALLAH
Middle Name:
Last Name:ABBOUD
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 1:5333 N CLARK ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-2121
Mailing Address - Country:US
Mailing Address - Phone:773-340-8318
Mailing Address - Fax:773-739-4300
Practice Address - Street 1:4049 W 26TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-3701
Practice Address - Country:US
Practice Address - Phone:773-521-2800
Practice Address - Fax:773-521-2805
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-25
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019028508122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist