MEDICARE: IMAD BAHRANI 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	019017511	IL

General Provider Information

NPI Number	:	1205907599
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IMAD BAHRANI DDS

Provider Business Mailing Address
First Line	:	4254 N MILWAUKEE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60641-1643
Country	:	US
Telephone Number	:	773-282-7906
Fax Number	:	773-427-2740

Provider Business Practice Location Address
First Line	:	4254 N MILWAUKEE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60641-1643
Country	:	US
Telephone Number	:	773-282-7906
Fax Number	:	773-427-2740

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

Provider Enumeration Date	:	11/10/2006
Last Update Date	:	11/18/2014

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