MEDICARE: SALIH DENTAL KEDZIE 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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1619458767
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SALIH DENTAL KEDZIE INC.

Provider Business Mailing Address
First Line	:	6235 S KEDZIE AVE UNIT 2
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60629-3304
Country	:	US
Telephone Number	:	773-853-0593
Fax Number	:	773-913-0508

Provider Business Practice Location Address
First Line	:	6235 S KEDZIE AVE UNIT 2
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60629-3304
Country	:	US
Telephone Number	:	773-853-0593
Fax Number	:	773-913-0508

Authorized Official
Title or Position	:	DR.
Name	:	EVA BLODA
Credential	:	DDS
Telephone Number	:	773-853-0593

Provider Enumeration Date	:	08/27/2018
Last Update Date	:	08/27/2018

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