MEDICARE: PRISTINE PEARLS 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

General Provider Information

NPI Number	:	1508685942
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRISTINE PEARLS LLC

Provider Business Mailing Address
First Line	:	2407 N MILWAUKEE AVE STE 101
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-6859
Country	:	US
Telephone Number	:	312-471-6555
Fax Number	:	312-471-6554

Provider Business Practice Location Address
First Line	:	2407 N MILWAUKEE AVE STE 101
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-6859
Country	:	US
Telephone Number	:	312-471-6555
Fax Number	:	312-471-6554

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	JASON BRODY
Credential	:
Telephone Number	:	312-471-6555

Provider Enumeration Date	:	10/03/2024
Last Update Date	:	10/03/2024

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Directions to “PRISTINE PEARLS LLC ” Practice Location

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