MEDICARE: DENTAL 360 PULASKI 67 LLC

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

General Provider Information

NPI Number	:	1235968587
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL 360 PULASKI 67 LLC

Provider Business Mailing Address
First Line	:	2759 W 55TH ST STE B
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 STE B
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	:	OWNER
Name	:	MOHAMMED PARVEZ
Credential	:
Telephone Number	:	630-294-1770

Provider Enumeration Date	:	07/26/2024
Last Update Date	:	07/26/2024

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