MEDICARE: CHATHAM DENTALWORKS 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	019025166	IL

General Provider Information

NPI Number	:	1730467796
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHATHAM DENTALWORKS PC

Provider Business Mailing Address
First Line	:	8803 S STONY ISLAND AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60617-2810
Country	:	US
Telephone Number	:	773-375-0303
Fax Number	:	773-375-9018

Provider Business Practice Location Address
First Line	:	8803 S STONY ISLAND AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60617-2810
Country	:	US
Telephone Number	:	773-375-0303
Fax Number	:	773-375-9018

Authorized Official
Title or Position	:	CEO
Name	:	DR. REGINALD T BAKER
Credential	:	D.D.S.
Telephone Number	:	773-375-0303

Provider Enumeration Date	:	07/25/2011
Last Update Date	:	07/25/2011

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