MEDICARE: LAWRENCE DENTAL GROUP P.C.

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

General Provider Information

NPI Number	:	1184776353
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAWRENCE DENTAL GROUP P.C.

Provider Business Mailing Address
First Line	:	3607 W LAWRENCE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-5605
Country	:	US
Telephone Number	:	773-588-7660
Fax Number	:

Provider Business Practice Location Address
First Line	:	3607 W LAWRENCE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-5605
Country	:	US
Telephone Number	:	773-588-7660
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. GEORGE KOROVILAS
Credential	:	D.D.S.
Telephone Number	:	773-588-7660

Provider Enumeration Date	:	01/17/2007
Last Update Date	:	08/22/2020

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