MEDICARE: DR. VILAS SASTRY DMD

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	122300000X	Dentist	5053	NV
2	122300000X	Dentist	019033030	IL
3	122300000X	Dentist	1002728	WI

General Provider Information

NPI Number	:	1104921279
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. VILAS SASTRY DMD

Provider Business Mailing Address
First Line	:	2828 WOODMERE CT
Second Line	:
City	:	NORTHBROOK
State	:	IL
Zip	:	60062-6447
Country	:	US
Telephone Number	:	702-332-2337
Fax Number	:

Provider Business Practice Location Address
First Line	:	6121 7TH AVE
Second Line	:
City	:	KENOSHA
State	:	WI
Zip	:	53143-4506
Country	:	US
Telephone Number	:	262-654-6535
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/14/2006
Last Update Date	:	05/02/2023

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