MEDICARE: AGARWAL 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	261QD0000X	Dental Clinic/Center
2	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1770661019
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AGARWAL DENTAL CLINIC

Provider Business Mailing Address
First Line	:	1501 S CALIFORNIA AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-1732
Country	:	US
Telephone Number	:	773-257-6770
Fax Number	:

Provider Business Practice Location Address
First Line	:	1415 EMERALD AVE
Second Line	:
City	:	CHICAGO HEIGHTS
State	:	IL
Zip	:	60411-3517
Country	:	US
Telephone Number	:	708-756-7384
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DONNA THOMPSON
Credential	:
Telephone Number	:	773-257-6770

Provider Enumeration Date	:	11/02/2006
Last Update Date	:	08/10/2007

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