MEDICARE: DR. MEREDITH GANTOS DDS, FAGD.

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	019.029792	IL
2	122300000X	Dentist	019.029792	IL

General Provider Information

NPI Number	:	1538574546
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MEREDITH GANTOS DDS, FAGD.

Provider Business Mailing Address
First Line	:	720 N WASHINGTON ST STE 106
Second Line	:
City	:	NAPERVILLE
State	:	IL
Zip	:	60563-3462
Country	:	US
Telephone Number	:	630-420-9090
Fax Number	:	630-420-8081

Provider Business Practice Location Address
First Line	:	720 N WASHINGTON ST STE 106
Second Line	:
City	:	NAPERVILLE
State	:	IL
Zip	:	60563-3462
Country	:	US
Telephone Number	:	630-420-9090
Fax Number	:	630-420-8081

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

Provider Enumeration Date	:	06/27/2014
Last Update Date	:	08/18/2021

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