MEDICARE: DR. JAYANTILAL T. MALLI DDS

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	:	1891784252
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAYANTILAL T. MALLI DDS

Provider Business Mailing Address
First Line	:	3441 W NORTH AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-4841
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3441 W NORTH AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-4841
Country	:	US
Telephone Number	:	773-276-6363
Fax Number	:

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

Provider Enumeration Date	:	10/18/2005
Last Update Date	:	07/08/2007

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