Provider Demographics
NPI:1730220450
Name:AL AZZAWI, BUSHRA A (DDS)
Entity type:Individual
Prefix:DR
First Name:BUSHRA
Middle Name:A
Last Name:AL AZZAWI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2545 W PETERSON AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-4091
Mailing Address - Country:US
Mailing Address - Phone:773-561-2808
Mailing Address - Fax:773-561-2809
Practice Address - Street 1:2545 W PETERSON AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-4091
Practice Address - Country:US
Practice Address - Phone:773-561-2808
Practice Address - Fax:773-561-2809
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190248721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice