MEDICARE: DENTAL IMPRESSION, SC

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	019025521	IL

General Provider Information

NPI Number	:	1235415548
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL IMPRESSION, SC

Provider Business Mailing Address
First Line	:	5430 S KEDZIE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60632-2620
Country	:	US
Telephone Number	:	773-925-0650
Fax Number	:

Provider Business Practice Location Address
First Line	:	5430 S KEDZIE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60632-2620
Country	:	US
Telephone Number	:	773-925-0650
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. SHAFEEQ H BADER
Credential	:	DDS
Telephone Number	:	630-452-6950

Provider Enumeration Date	:	11/01/2011
Last Update Date	:	11/01/2011

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