MEDICARE: VLADIK CRUTCHER DMD 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	:	1144873506
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VLADIK CRUTCHER DMD LLC

Provider Business Mailing Address
First Line	:	1545 W NORTH AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60642-2530
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1545 W NORTH AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60642-2530
Country	:	US
Telephone Number	:	312-584-0355
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. VLADIK CRUTCHER
Credential	:	DMD
Telephone Number	:	312-584-0355

Provider Enumeration Date	:	07/24/2019
Last Update Date	:	03/06/2020

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