MEDICARE: DEVON DENTAL SURGERY, LTD

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1467624270
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEVON DENTAL SURGERY, LTD

Provider Business Mailing Address
First Line	:	1522 W CHICAGO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-5236
Country	:	US
Telephone Number	:	312-733-5811
Fax Number	:	312-733-9511

Provider Business Practice Location Address
First Line	:	1522 W CHICAGO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-5236
Country	:	US
Telephone Number	:	312-733-5811
Fax Number	:	312-733-9511

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. NINA N SANAI
Credential	:	D.D.S.
Telephone Number	:	312-733-5811

Provider Enumeration Date	:	04/01/2008
Last Update Date	:	04/01/2008

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