MEDICARE: NEETHARA ABRAHAM DMD

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	019.035167	IL

General Provider Information

NPI Number	:	1679317481
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NEETHARA ABRAHAM DMD

Provider Business Mailing Address
First Line	:	2390 LEGACY DR
Second Line	:
City	:	AURORA
State	:	IL
Zip	:	60502-1368
Country	:	US
Telephone Number	:	630-853-3722
Fax Number	:

Provider Business Practice Location Address
First Line	:	1726 W 18TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-3994
Country	:	US
Telephone Number	:	312-733-7454
Fax Number	:

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

Provider Enumeration Date	:	06/25/2024
Last Update Date	:	06/26/2024

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Directions to “ NEETHARA ABRAHAM DMD” Practice Location

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