MEDICARE: ENGLEWOOD DENTAL CARE

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

General Provider Information

NPI Number	:	1497066856
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ENGLEWOOD DENTAL CARE

Provider Business Mailing Address
First Line	:	4332 N ELSTON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60641-2144
Country	:	US
Telephone Number	:	773-754-3500
Fax Number	:	773-754-3504

Provider Business Practice Location Address
First Line	:	7114 S VINCENNES AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60621-3506
Country	:	US
Telephone Number	:	773-244-4800
Fax Number	:	773-244-4807

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. MIRZA BAIG
Credential	:
Telephone Number	:	773-244-4800

Provider Enumeration Date	:	06/30/2010
Last Update Date	:	06/30/2010

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Directions to “ENGLEWOOD DENTAL CARE ” Practice Location

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