MEDICARE: WEST TOWN DENTAL GROUP

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	01915779	IL

General Provider Information

NPI Number	:	1326038738
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEST TOWN DENTAL GROUP

Provider Business Mailing Address
First Line	:	1229 N ASHLAND AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-2204
Country	:	US
Telephone Number	:	773-252-5772
Fax Number	:	773-278-0543

Provider Business Practice Location Address
First Line	:	1229 N ASHLAND AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-2204
Country	:	US
Telephone Number	:	773-252-5772
Fax Number	:	773-278-0543

Authorized Official
Title or Position	:	OWNER
Name	:	SABAH H KHALIFA
Credential	:
Telephone Number	:	773-252-5772

Provider Enumeration Date	:	10/26/2005
Last Update Date	:	08/22/2020

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Directions to “WEST TOWN DENTAL GROUP ” Practice Location

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