MEDICARE: LEE C DRAHOS, DDS, PC

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	019025635	IL

General Provider Information

NPI Number	:	1306176615
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEE C DRAHOS, DDS, PC

Provider Business Mailing Address
First Line	:	6800 W ARCHER AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60638-2312
Country	:	US
Telephone Number	:	773-788-1001
Fax Number	:	773-788-1388

Provider Business Practice Location Address
First Line	:	6800 W ARCHER AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60638-2312
Country	:	US
Telephone Number	:	773-788-1001
Fax Number	:	773-788-1388

Authorized Official
Title or Position	:	GENERAL DENTIST
Name	:	DR. LEE C DRAHOS
Credential	:	DDS
Telephone Number	:	773-788-1001

Provider Enumeration Date	:	01/08/2010
Last Update Date	:	01/08/2010

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