MEDICARE: DR. GREGORY AMADEO BERTAGNA D.D.S.

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	1223G0001X	General Practice Dentistry	019017754	IL

General Provider Information

NPI Number	:	1164439907
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GREGORY AMADEO BERTAGNA D.D.S.

Provider Business Mailing Address
First Line	:	8225 GRAND AVE
Second Line	:	SUITE 200
City	:	RIVER GROVE
State	:	IL
Zip	:	60171-1517
Country	:	US
Telephone Number	:	708-453-1110
Fax Number	:	708-452-0157

Provider Business Practice Location Address
First Line	:	8383 BELMONT AVE
Second Line	:	SUITE 200
City	:	RIVER GROVE
State	:	IL
Zip	:	60171-1000
Country	:	US
Telephone Number	:	708-453-1110
Fax Number	:	708-452-0157

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

Provider Enumeration Date	:	08/02/2006
Last Update Date	:	03/31/2016

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