MEDICARE: PLAZA DENTAL GROUP, 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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1558744649
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PLAZA DENTAL GROUP, LTD.

Provider Business Mailing Address
First Line	:	3338 N HARLEM AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60634-3601
Country	:	US
Telephone Number	:	773-637-8696
Fax Number	:	773-637-8666

Provider Business Practice Location Address
First Line	:	3338 N HARLEM AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60634-3601
Country	:	US
Telephone Number	:	773-637-8696
Fax Number	:	773-637-8666

Authorized Official
Title or Position	:	OFFICER
Name	:	DR. VINCENT A. GASPARAITIS JR.
Credential	:	D.D.S.
Telephone Number	:	773-637-8696

Provider Enumeration Date	:	07/07/2015
Last Update Date	:	07/07/2015

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Directions to “PLAZA DENTAL GROUP, LTD. ” Practice Location

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