MEDICARE: INDEPENDENCE FAMILY 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	122300000X	Dentist		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164406138
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDEPENDENCE FAMILY DENTAL

Provider Business Mailing Address
First Line	:	4703 W LAWRENCE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60630-1722
Country	:	US
Telephone Number	:	773-205-9900
Fax Number	:	773-205-9970

Provider Business Practice Location Address
First Line	:	4703 W LAWRENCE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60630-1722
Country	:	US
Telephone Number	:	773-205-9900
Fax Number	:	773-205-9970

Authorized Official
Title or Position	:	DENTIST
Name	:	EMAD E AZAB
Credential	:	DDS
Telephone Number	:	773-205-9900

Provider Enumeration Date	:	12/02/2005
Last Update Date	:	08/22/2020

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Directions to “INDEPENDENCE FAMILY DENTAL ” Practice Location

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