MEDICARE: CHICAGO MALL DENTAL ASSOCIATES, 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		IL

General Provider Information

NPI Number	:	1245741578
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHICAGO MALL DENTAL ASSOCIATES, LLC

Provider Business Mailing Address
First Line	:	7501 W CERMAK RD STE F16
Second Line	:
City	:	NORTH RIVERSIDE
State	:	IL
Zip	:	60546-2815
Country	:	US
Telephone Number	:	708-402-8001
Fax Number	:

Provider Business Practice Location Address
First Line	:	7501 W CERMAK RD STE F16
Second Line	:
City	:	NORTH RIVERSIDE
State	:	IL
Zip	:	60546-2815
Country	:	US
Telephone Number	:	708-402-8001
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ROSTISLAV KRASNOV
Credential	:
Telephone Number	:	786-475-7600

Provider Enumeration Date	:	10/13/2017
Last Update Date	:	10/13/2017

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