Healthcare Provider Details

I. General information

NPI: 1730556101
Provider Name (Legal Business Name): CRESTWOOD DENTAL AND TMJ CARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2015
Last Update Date: 08/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13549 CICERO AVE
CRESTWOOD IL
60445-1934
US

IV. Provider business mailing address

13549 CICERO AVE
CRESTWOOD IL
60445-1934
US

V. Phone/Fax

Practice location:
  • Phone: 708-388-3200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019024802
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. KEVIN BARGAMIAN
Title or Position: PRESIDENT
Credential:
Phone: 708-388-3200