Provider Demographics
NPI:1447936000
Name:AHMAD, FAYEK
Entity type:Individual
Prefix:
First Name:FAYEK
Middle Name:
Last Name:AHMAD
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 1:5003 W ROSCOE ST APT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-4202
Mailing Address - Country:US
Mailing Address - Phone:773-558-7186
Mailing Address - Fax:
Practice Address - Street 1:2937 N. STATE IL-178
Practice Address - Street 2:SUITE 2
Practice Address - City:UTICA
Practice Address - State:IL
Practice Address - Zip Code:61373
Practice Address - Country:US
Practice Address - Phone:815-993-3101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-27
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.034384122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist