MEDICARE: EZ DENTAL

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	292200000X	Dental Laboratory	019023027	IL

General Provider Information

NPI Number	:	1104284710
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EZ DENTAL

Provider Business Mailing Address
First Line	:	5621 W.MONTROSE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60634
Country	:	US
Telephone Number	:	773-427-1000
Fax Number	:

Provider Business Practice Location Address
First Line	:	5621 W.MONTROSE AVENUE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60634
Country	:	US
Telephone Number	:	773-427-1000
Fax Number	:

Authorized Official
Title or Position	:	BOSS
Name	:	ABDUL MAJZOUB
Credential	:
Telephone Number	:	773-583-4455

Provider Enumeration Date	:	02/10/2016
Last Update Date	:	02/10/2016

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Directions to “EZ DENTAL ” Practice Location

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