MEDICARE: DR. SAMUEL GRANDINETTI 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	019024845	IL

General Provider Information

NPI Number	:	1558405225
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SAMUEL GRANDINETTI DDS

Provider Business Mailing Address
First Line	:	7417 LAVERGNE AVE
Second Line	:
City	:	SKOKIE
State	:	IL
Zip	:	60077-3328
Country	:	US
Telephone Number	:	847-673-8162
Fax Number	:

Provider Business Practice Location Address
First Line	:	7215 W TOUHY AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60631-4386
Country	:	US
Telephone Number	:	773-775-3431
Fax Number	:

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

Provider Enumeration Date	:	02/16/2007
Last Update Date	:	07/08/2007

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