Provider Demographics
NPI:1902279722
Name:TAHBAZ, SAM (DDS)
Entity Type:Individual
Prefix:MR
First Name:SAM
Middle Name:
Last Name:TAHBAZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1504 N. WELLS STREET
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60160
Mailing Address - Country:US
Mailing Address - Phone:312-573-0007
Mailing Address - Fax:312-573-0002
Practice Address - Street 1:1504 N WELLS STREET
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60610
Practice Address - Country:US
Practice Address - Phone:312-573-0007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-02
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-024892122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist