MEDICARE: PEARL DENTAL 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	261QD0000X	Dental Clinic/Center	019024870	IL

General Provider Information

NPI Number	:	1558649368
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEARL DENTAL LLC

Provider Business Mailing Address
First Line	:	4527 N PULASKI RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60630-4415
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4527 N PULASKI RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60630-4415
Country	:	US
Telephone Number	:	630-240-1984
Fax Number	:

Authorized Official
Title or Position	:	DDS
Name	:	FAWAZ KANNOUT
Credential	:
Telephone Number	:	630-240-1984

Provider Enumeration Date	:	07/27/2011
Last Update Date	:	07/27/2011

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Directions to “PEARL DENTAL LLC ” Practice Location

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