MEDICARE: JASON DIFANI, DDS, 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	122300000X	Dentist	019027928	IL

General Provider Information

NPI Number	:	1689960593
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JASON DIFANI, DDS, PC

Provider Business Mailing Address
First Line	:	1843 W ROSCOE ST APT 1
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-1102
Country	:	US
Telephone Number	:	309-824-8835
Fax Number	:

Provider Business Practice Location Address
First Line	:	5050 S KEDZIE AVE UNIT A
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60632-3009
Country	:	US
Telephone Number	:	773-778-2200
Fax Number	:	773-778-2202

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JASON T DIFANI
Credential	:	DDS
Telephone Number	:	309-824-8835

Provider Enumeration Date	:	06/20/2011
Last Update Date	:	06/20/2011

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