MEDICARE: PRECISION DENTAL CARE 5 LLC

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	019026820	IL

General Provider Information

NPI Number	:	1376915348
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRECISION DENTAL CARE 5 LLC

Provider Business Mailing Address
First Line	:	6930 S PULASKI RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60629-4223
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5745 W BELMONT AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60634-5211
Country	:	US
Telephone Number	:	773-284-5510
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KHANH NGUYEN
Credential	:	D.D.S.
Telephone Number	:	773-284-5510

Provider Enumeration Date	:	10/29/2015
Last Update Date	:	10/29/2015

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