MEDICARE: BRITE DENTAL 55, 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	019026128	IL

General Provider Information

NPI Number	:	1205180775
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRITE DENTAL 55, P.C

Provider Business Mailing Address
First Line	:	2759 W 55TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60632-2251
Country	:	US
Telephone Number	:	773-776-5277
Fax Number	:	773-776-5278

Provider Business Practice Location Address
First Line	:	2759 W 55TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60632-2251
Country	:	US
Telephone Number	:	773-776-5277
Fax Number	:	773-776-5278

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. FADI M AQEL
Credential	:	DDS
Telephone Number	:	708-439-4655

Provider Enumeration Date	:	11/05/2012
Last Update Date	:	11/05/2012

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