Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | 019.031565 | IL |
NPI | 1083192389 |
---|---|
Provider Name | Dr. Amirreza Ghassemi |
First Address | Alton, IL 62002-4742 |
Second Address | Alton, IL 62002-4742 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/07/2018 |
Last Update Date | 30/07/2018 |