Healthcare Provider Details

I. General information

NPI: 1851896286
Provider Name (Legal Business Name): KETAN S BEDMUTHA DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2018
Last Update Date: 04/24/2021
Certification Date: 04/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 W CERMAK RD
CHICAGO IL
60608-4204
US

IV. Provider business mailing address

601 W JACKSON BLVD UNIT 1404
CHICAGO IL
60661-5642
US

V. Phone/Fax

Practice location:
  • Phone: 773-376-2777
  • Fax:
Mailing address:
  • Phone: 716-725-1593
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.032066
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: