MEDICARE: ROHAN BANSAL

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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	018002174	IL
2	390200000X	Student in an Organized Health Care Education/Training Program
3	1223G0001X	General Practice Dentistry	019033432	IL

General Provider Information

NPI Number	:	1306423314
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROHAN BANSAL

Provider Business Mailing Address
First Line	:	8704 RIDGELAND AVE
Second Line	:
City	:	OAK LAWN
State	:	IL
Zip	:	60453-1068
Country	:	US
Telephone Number	:	708-430-4440
Fax Number	:

Provider Business Practice Location Address
First Line	:	8704 RIDGELAND AVE
Second Line	:
City	:	OAK LAWN
State	:	IL
Zip	:	60453-1068
Country	:	US
Telephone Number	:	708-430-4440
Fax Number	:

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

Provider Enumeration Date	:	03/25/2021
Last Update Date	:	06/20/2022

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Directions to “ ROHAN BANSAL ” Practice Location

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