MEDICARE: GREATER CHICAGO DENTAL ASSOCIATES, INC.

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	019.027200	IL

General Provider Information

NPI Number	:	1538335971
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREATER CHICAGO DENTAL ASSOCIATES, INC.

Provider Business Mailing Address
First Line	:	4600 S PULASKI RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60632-4038
Country	:	US
Telephone Number	:	773-376-1111
Fax Number	:	773-376-3099

Provider Business Practice Location Address
First Line	:	4600 S PULASKI RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60632-4038
Country	:	US
Telephone Number	:	773-376-1111
Fax Number	:	773-376-3099

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. RAMON JUAN RODRIGUEZ
Credential	:	D.M.D.
Telephone Number	:	773-376-1111

Provider Enumeration Date	:	05/06/2008
Last Update Date	:	05/06/2008

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