MEDICARE: JEFFERY DENTAL CENTER

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		IL

General Provider Information

NPI Number	:	1457449571
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JEFFERY DENTAL CENTER

Provider Business Mailing Address
First Line	:	7615 S JEFFERY BLVD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60649-4015
Country	:	US
Telephone Number	:	773-374-9900
Fax Number	:	773-374-9422

Provider Business Practice Location Address
First Line	:	7615 S JEFFERY BLVD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60649-4015
Country	:	US
Telephone Number	:	773-374-9900
Fax Number	:	773-374-9422

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	KRISTINE M KOWALSKI
Credential	:
Telephone Number	:	773-374-9900

Provider Enumeration Date	:	10/11/2006
Last Update Date	:	07/21/2022

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