Provider Demographics
NPI:1871163576
Name:RAZZAK, MERVA
Entity type:Individual
Prefix:
First Name:MERVA
Middle Name:
Last Name:RAZZAK
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 1:2113 DALY LN
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60586-2565
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16906 OAK PARK AVE
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-3075
Practice Address - Country:US
Practice Address - Phone:708-444-7645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-25
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0346331223P0221X
390200000X
IL021.0032931223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program