MEDICARE: DR. REGINALD ODOM DDS

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	019021471	IL

General Provider Information

NPI Number	:	1548329386
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. REGINALD ODOM DDS

Provider Business Mailing Address
First Line	:	570 E 115TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60628-5740
Country	:	US
Telephone Number	:	773-768-5000
Fax Number	:

Provider Business Practice Location Address
First Line	:	4109 W 47TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60632-4101
Country	:	US
Telephone Number	:	773-847-6740
Fax Number	:	773-874-6745

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

Provider Enumeration Date	:	12/07/2006
Last Update Date	:	02/29/2016

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