MEDICARE: EAST DENTAL LTD

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	122300000X	Dentist	019026287	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1528211778
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST DENTAL LTD

Provider Business Mailing Address
First Line	:	3916 N CICERO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60641-2709
Country	:	US
Telephone Number	:	773-283-3513
Fax Number	:

Provider Business Practice Location Address
First Line	:	3916 N CICERO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60641-2709
Country	:	US
Telephone Number	:	773-283-3513
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ASHRAF AHMAD
Credential	:
Telephone Number	:	773-283-3513

Provider Enumeration Date	:	11/01/2008
Last Update Date	:	11/01/2008

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Directions to “EAST DENTAL LTD ” Practice Location

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