Provider Demographics
NPI:1053167999
Name:MOHAMAD, MAMOON SALAMAH (DMD)
Entity type:Individual
Prefix:DR
First Name:MAMOON
Middle Name:SALAMAH
Last Name:MOHAMAD
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 1:4305 N OLCOTT AVE
Mailing Address - Street 2:
Mailing Address - City:NORRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60706-1138
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3138 N NARRAGANSETT AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-4919
Practice Address - Country:US
Practice Address - Phone:773-745-6410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-30
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL019.0350601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program