MEDICARE: SECURE 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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1104751551
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SECURE DENTAL LLC

Provider Business Mailing Address
First Line	:	502 RIVERSIDE DR
Second Line	:
City	:	EAST PEORIA
State	:	IL
Zip	:	61611-2068
Country	:	US
Telephone Number	:	309-606-5008
Fax Number	:

Provider Business Practice Location Address
First Line	:	5621 W MONTROSE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60634-1830
Country	:	US
Telephone Number	:	733-427-1000
Fax Number	:

Authorized Official
Title or Position	:	OWNER DENTIST
Name	:	NAZISH HASAN JAFRI
Credential	:	DDS
Telephone Number	:	309-606-5008

Provider Enumeration Date	:	06/16/2026
Last Update Date	:	06/16/2026

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Directions to “SECURE DENTAL LLC ” Practice Location

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