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General NPI Number Information
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NPI Number | 1851896286
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Entity Type | Individual
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Provider Name | KETAN S BEDMUTHA DMD
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Gender | Male
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Dates
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Enumeration Date | 03/27/2018
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Last Update Date | 04/24/2021
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Provider Practice Location Address
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Address Line | 1950 W CERMAK RD
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City | CHICAGO
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State | IL
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Zip | 60608-4204
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Country | US
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Telephone | 773-376-2777
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Fax |
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Provider Business Mailing Address
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Address Line | 601 W JACKSON BLVD UNIT 1404
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City | CHICAGO
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State | IL
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Zip | 60661-5642
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Country | US
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Telephone | 716-725-1593
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 019.032066
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License Number State | IL
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