Provider Demographics
NPI:1750958377
Name:BUSOUL, REEMA (DMD)
Entity type:Individual
Prefix:DR
First Name:REEMA
Middle Name:
Last Name:BUSOUL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3904 PERSHING AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-4411
Mailing Address - Country:US
Mailing Address - Phone:817-247-1479
Mailing Address - Fax:
Practice Address - Street 1:2101 E 71ST ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60649-2143
Practice Address - Country:US
Practice Address - Phone:177-324-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-10
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0331461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice