MEDICARE: HERMOSA 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	1915779	IL

General Provider Information

NPI Number	:	1801887583
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HERMOSA DENTAL CLINIC

Provider Business Mailing Address
First Line	:	2004 N PULASKI RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60639
Country	:	US
Telephone Number	:	773-342-5923
Fax Number	:	773-342-0835

Provider Business Practice Location Address
First Line	:	2004 N PULASKI RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60639
Country	:	US
Telephone Number	:	773-342-5923
Fax Number	:	773-342-0835

Authorized Official
Title or Position	:	OWNER
Name	:	SABAH H KHALIFA
Credential	:	DDS
Telephone Number	:	773-342-5923

Provider Enumeration Date	:	11/02/2005
Last Update Date	:	08/22/2020

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Directions to “HERMOSA DENTAL CLINIC ” Practice Location

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