MEDICARE: TRESVANT DENTAL GROUP

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	019027070	IL

General Provider Information

NPI Number	:	1538306071
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRESVANT DENTAL GROUP

Provider Business Mailing Address
First Line	:	1813 S DESPLAINES ST
Second Line	:	UNIT 1
City	:	CHICAGO
State	:	IL
Zip	:	60616-1033
Country	:	US
Telephone Number	:	312-672-2877
Fax Number	:

Provider Business Practice Location Address
First Line	:	1813 S DESPLAINES ST
Second Line	:	UNIT 1
City	:	CHICAGO
State	:	IL
Zip	:	60616-1033
Country	:	US
Telephone Number	:	312-672-2877
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DR. TAMAARA ANGELA MORRIS
Credential	:	DDS
Telephone Number	:	312-672-2877

Provider Enumeration Date	:	01/20/2009
Last Update Date	:	01/20/2009

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