MEDICARE: DUBRAVEC PERIODONTAL ASSOCIATES, 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	1223P0300X	Periodontics	019021633	IL

General Provider Information

NPI Number	:	1114398831
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DUBRAVEC PERIODONTAL ASSOCIATES, PC

Provider Business Mailing Address
First Line	:	20635 ABBEY WOODS CT N
Second Line	:	SUITE 203
City	:	FRANKFORT
State	:	IL
Zip	:	60423-3181
Country	:	US
Telephone Number	:	815-464-3001
Fax Number	:	815-464-3010

Provider Business Practice Location Address
First Line	:	1900 SPRING RD
Second Line	:	SUITE 205
City	:	OAK BROOK
State	:	IL
Zip	:	60523-1447
Country	:	US
Telephone Number	:	630-573-0369
Fax Number	:	630-573-0234

Authorized Official
Title or Position	:	OWNER
Name	:	DOMINIK B. DUBRAVEC
Credential	:	DDS, MMSC
Telephone Number	:	815-464-3001

Provider Enumeration Date	:	10/08/2015
Last Update Date	:	10/08/2015

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