MEDICARE: ULTIMATE DENTAL PARTNERS, 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	122300000X	Dentist	019026667	IL

General Provider Information

NPI Number	:	1629584891
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ULTIMATE DENTAL PARTNERS, LLC

Provider Business Mailing Address
First Line	:	4254 N MILWAUKEE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60641-1643
Country	:	US
Telephone Number	:	773-282-7906
Fax Number	:	773-427-2740

Provider Business Practice Location Address
First Line	:	4254 N MILWAUKEE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60641-1643
Country	:	US
Telephone Number	:	773-282-7906
Fax Number	:	773-427-2740

Authorized Official
Title or Position	:	MANAGER/ PARTNER
Name	:	DR. SIBTAIN KERAI
Credential	:	DDS
Telephone Number	:	312-231-7601

Provider Enumeration Date	:	12/23/2017
Last Update Date	:	12/23/2017

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