MEDICARE: GRAND DENTISTRY

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	019028510	IL

General Provider Information

NPI Number	:	1295145092
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRAND DENTISTRY

Provider Business Mailing Address
First Line	:	116 W GRAND AVE
Second Line	:	#1
City	:	CHICAGO
State	:	IL
Zip	:	60654-5207
Country	:	US
Telephone Number	:	312-955-9020
Fax Number	:

Provider Business Practice Location Address
First Line	:	116 W GRAND AVE
Second Line	:	#1
City	:	CHICAGO
State	:	IL
Zip	:	60654-5207
Country	:	US
Telephone Number	:	312-955-9020
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. DEEPAN PRAVIN PATEL
Credential	:	DND
Telephone Number	:	616-443-5097

Provider Enumeration Date	:	05/01/2014
Last Update Date	:	05/01/2014

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Directions to “GRAND DENTISTRY ” Practice Location

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