MEDICARE: IRVING PARK DENTISTRY, INC.

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

General Provider Information

NPI Number	:	1376847137
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IRVING PARK DENTISTRY, INC.

Provider Business Mailing Address
First Line	:	1933 W IRVING PARK RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-5180
Country	:	US
Telephone Number	:	312-919-6266
Fax Number	:

Provider Business Practice Location Address
First Line	:	1933 W IRVING PARK RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-5180
Country	:	US
Telephone Number	:	312-919-6266
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	NADA ZAYZAFOON
Credential	:	DMD
Telephone Number	:	312-919-6266

Provider Enumeration Date	:	01/07/2011
Last Update Date	:	01/07/2011

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