MEDICARE: LUIS GREGORIO GRANADOS PAUCAR DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	019032351	IL

General Provider Information

NPI Number	:	1063948222
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LUIS GREGORIO GRANADOS PAUCAR DDS

Provider Business Mailing Address
First Line	:	1660 GLEN ELLYN RD
Second Line	:
City	:	GLENDALE HEIGHTS
State	:	IL
Zip	:	60139-2504
Country	:	US
Telephone Number	:	630-474-0976
Fax Number	:

Provider Business Practice Location Address
First Line	:	1660 GLEN ELLYN RD
Second Line	:
City	:	GLENDALE HEIGHTS
State	:	IL
Zip	:	60139-2504
Country	:	US
Telephone Number	:	630-474-0976
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/10/2017
Last Update Date	:	04/10/2025

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