MEDICARE: MT. GREENWOOD DENTAL CLINIC

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	019016104	IL

General Provider Information

NPI Number	:	1558637926
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MT. GREENWOOD DENTAL CLINIC

Provider Business Mailing Address
First Line	:	3135 W 111TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60655-2223
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3135 W 111TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60655-2223
Country	:	US
Telephone Number	:	773-238-4451
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. KENNETH BROCKER
Credential	:	D.D.S.
Telephone Number	:	773-238-4451

Provider Enumeration Date	:	03/29/2012
Last Update Date	:	03/29/2012

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