Provider Demographics
NPI:1861610842
Name:TAHERI, MOHAMMAD H (DMD)
Entity type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:H
Last Name:TAHERI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 W WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60661-2117
Mailing Address - Country:US
Mailing Address - Phone:312-939-8550
Mailing Address - Fax:
Practice Address - Street 1:630 W WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60661-2117
Practice Address - Country:US
Practice Address - Phone:312-939-8550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2025-02-05
Deactivation Date:2025-01-19
Deactivation Code:
Reactivation Date:2025-01-28
Provider Licenses
StateLicense IDTaxonomies
IL021.0032031223P0700X
IL019.0335051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223P0700XDental ProvidersDentistProsthodontics