MEDICARE: DR. CORY A GRATHWOL D.M.D.

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	390200000X	Student in an Organized Health Care Education/Training Program		OH
2	1223P0221X	Pediatric Dentistry	019031567	IL

General Provider Information

NPI Number	:	1467802736
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CORY A GRATHWOL D.M.D.

Provider Business Mailing Address
First Line	:	47 E CHICAGO AVE STE 344
Second Line	:
City	:	NAPERVILLE
State	:	IL
Zip	:	60540-5360
Country	:	US
Telephone Number	:	630-778-9500
Fax Number	:	630-778-9521

Provider Business Practice Location Address
First Line	:	47 E CHICAGO AVE STE 344
Second Line	:
City	:	NAPERVILLE
State	:	IL
Zip	:	60540-5360
Country	:	US
Telephone Number	:	630-778-9500
Fax Number	:	630-778-9521

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/17/2016
Last Update Date	:	04/05/2022

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