MEDICARE: DENTAL MAGIC NORTH AVE, INC

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	019024297	IL

General Provider Information

NPI Number	:	1104274109
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL MAGIC NORTH AVE, INC

Provider Business Mailing Address
First Line	:	2500 W NORTH AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-5202
Country	:	US
Telephone Number	:	773-360-1281
Fax Number	:	773-360-1285

Provider Business Practice Location Address
First Line	:	2500 W NORTH AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-5202
Country	:	US
Telephone Number	:	773-360-1281
Fax Number	:	773-360-1285

Authorized Official
Title or Position	:	OWNER
Name	:	SAWSAN ASFOUR
Credential	:	DDS
Telephone Number	:	773-360-1281

Provider Enumeration Date	:	05/31/2016
Last Update Date	:	05/31/2016

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