MEDICARE: DR. LARRY R ABDULLAH DDS

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	19A14729	IL

General Provider Information

NPI Number	:	1265463103
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LARRY R ABDULLAH DDS

Provider Business Mailing Address
First Line	:	7013 S WESTERN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60636-3121
Country	:	US
Telephone Number	:	773-476-0600
Fax Number	:

Provider Business Practice Location Address
First Line	:	7013 S WESTERN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60636-3121
Country	:	US
Telephone Number	:	773-476-0600
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/06/2006
Last Update Date	:	07/08/2007

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