MEDICARE: MAJOR DENTAL PC

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	019027819	IL

General Provider Information

NPI Number	:	1558598060
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAJOR DENTAL PC

Provider Business Mailing Address
First Line	:	3208 N MAJOR AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60634-4332
Country	:	US
Telephone Number	:	773-777-1111
Fax Number	:	773-777-0730

Provider Business Practice Location Address
First Line	:	3208 N MAJOR AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60634-4332
Country	:	US
Telephone Number	:	773-777-1111
Fax Number	:	773-777-0730

Authorized Official
Title or Position	:	PRESIDENT
Name	:	AGNIESZKA DOMAGALA
Credential	:	D.D.S.
Telephone Number	:	773-777-1111

Provider Enumeration Date	:	06/11/2009
Last Update Date	:	06/11/2009

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Directions to “MAJOR DENTAL PC ” Practice Location

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