=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689056665
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TERRENCE L. GRAFF DDS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2015
-----------------------------------------------------
Last Update Date | 06/25/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10741 165TH ST
-----------------------------------------------------
City | ORLAND PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60467-8713
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-364-1155
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10741 165TH ST
-----------------------------------------------------
City | ORLAND PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60467-8713
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | TERRENCE L GRAFF
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 708-364-1155
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 019.014568
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------