MEDICARE: IMAGE DENTAL LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	019027470	IL

General Provider Information

NPI Number	:	1063789584
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMAGE DENTAL LLC

Provider Business Mailing Address
First Line	:	3020 S CICERO AVE
Second Line	:
City	:	CICERO
State	:	IL
Zip	:	60804-3638
Country	:	US
Telephone Number	:	708-863-2000
Fax Number	:

Provider Business Practice Location Address
First Line	:	3020 S CICERO AVE
Second Line	:
City	:	CICERO
State	:	IL
Zip	:	60804-3638
Country	:	US
Telephone Number	:	708-863-2000
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. SINAN RAZZAK
Credential	:	DMD
Telephone Number	:	708-863-2000

Provider Enumeration Date	:	11/29/2011
Last Update Date	:	03/25/2012

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Directions to “IMAGE DENTAL LLC ” Practice Location

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