MEDICARE: KING DENTAL, PC

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

General Provider Information

NPI Number	:	1558993758
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KING DENTAL, PC

Provider Business Mailing Address
First Line	:	3425 S KING DR
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616
Country	:	US
Telephone Number	:	312-313-9777
Fax Number	:	312-736-0867

Provider Business Practice Location Address
First Line	:	3425 S KING DR
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616
Country	:	US
Telephone Number	:	312-313-9777
Fax Number	:	312-736-0867

Authorized Official
Title or Position	:	DENTIST
Name	:	NISHU SHARMA
Credential	:
Telephone Number	:	312-313-9777

Provider Enumeration Date	:	02/06/2020
Last Update Date	:	10/13/2020

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