MEDICARE: DENTAL IMAGE

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		IL

General Provider Information

NPI Number	:	1841464989
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL IMAGE

Provider Business Mailing Address
First Line	:	4724 N KEDZIE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-4421
Country	:	US
Telephone Number	:	773-583-4455
Fax Number	:	773-583-8986

Provider Business Practice Location Address
First Line	:	4724 N KEDZIE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-4421
Country	:	US
Telephone Number	:	773-583-4455
Fax Number	:	773-583-8986

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. TERRI CRUZ
Credential	:
Telephone Number	:	773-583-4455

Provider Enumeration Date	:	04/19/2008
Last Update Date	:	04/19/2008

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Directions to “DENTAL IMAGE ” Practice Location

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