Provider Demographics
NPI:1679163208
Name:SAHLOUL DENTAL, LLC
Entity type:Organization
Organization Name:SAHLOUL DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MONA
Authorized Official - Middle Name:
Authorized Official - Last Name:MANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-697-8105
Mailing Address - Street 1:9830 RIDGELAND AVE STE 5
Mailing Address - Street 2:
Mailing Address - City:CHICAGO RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60415-2668
Mailing Address - Country:US
Mailing Address - Phone:708-636-6424
Mailing Address - Fax:
Practice Address - Street 1:9830 RIDGELAND AVE STE 5
Practice Address - Street 2:
Practice Address - City:CHICAGO RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60415-2668
Practice Address - Country:US
Practice Address - Phone:708-636-6424
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-18
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100088321Medicaid