MEDICARE: SECURE DENTAL X PLLC

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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1245893189
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SECURE DENTAL X PLLC

Provider Business Mailing Address
First Line	:	502 RIVERSIDE DR
Second Line	:
City	:	EAST PEORIA
State	:	IL
Zip	:	61611-2068
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1828 W FOSTER AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-1479
Country	:	US
Telephone Number	:	309-606-5008
Fax Number	:

Authorized Official
Title or Position	:	OWNER, DENTIST
Name	:	NAZISH JAFRI
Credential	:	DDS
Telephone Number	:	815-708-2762

Provider Enumeration Date	:	04/16/2019
Last Update Date	:	04/16/2019

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