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General NPI Number Information
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NPI Number | 1558637926
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Entity Type | Organization
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Legal Business Name | MT. GREENWOOD DENTAL CLINIC
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Dates
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Enumeration Date | 03/29/2012
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Last Update Date | 03/29/2012
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Provider Practice Location Address
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Address Line | 3135 W 111TH ST
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City | CHICAGO
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State | IL
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Zip | 60655-2223
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Country | US
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Telephone | 773-238-4451
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Fax |
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Provider Business Mailing Address
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Address Line | 3135 W 111TH ST
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City | CHICAGO
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State | IL
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Zip | 60655-2223
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. KENNETH BROCKER
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Credential | D.D.S.
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Telephone | 773-238-4451
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019016104
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License Number State | IL
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