MEDICARE: VICTOR J. GRANDINETTI, DDS, PC

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	019024774	IL

General Provider Information

NPI Number	:	1104245950
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VICTOR J. GRANDINETTI, DDS, PC

Provider Business Mailing Address
First Line	:	7215 W TOUHY AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60631-4386
Country	:	US
Telephone Number	:	312-217-3333
Fax Number	:

Provider Business Practice Location Address
First Line	:	7215 W TOUHY AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60631-4386
Country	:	US
Telephone Number	:	312-217-3333
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	TINA GRANDINETTI
Credential	:
Telephone Number	:	312-217-3333

Provider Enumeration Date	:	04/09/2014
Last Update Date	:	04/09/2014

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