Provider Demographics
NPI:1265285167
Name:FULLERTON DENTAL ISLAND LLC
Entity type:Organization
Organization Name:FULLERTON DENTAL ISLAND LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WISAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MUSA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:312-709-1722
Mailing Address - Street 1:5836 W 100TH PL
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-3774
Mailing Address - Country:US
Mailing Address - Phone:312-709-1722
Mailing Address - Fax:
Practice Address - Street 1:5205 W FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-1401
Practice Address - Country:US
Practice Address - Phone:312-709-1722
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-09
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty