MEDICARE: AQUA DENTAL OF CHICAGO

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	019027018	IL

General Provider Information

NPI Number	:	1700194776
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AQUA DENTAL OF CHICAGO

Provider Business Mailing Address
First Line	:	2346 W CERMAK RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-3812
Country	:	US
Telephone Number	:	773-579-9480
Fax Number	:	773-579-9481

Provider Business Practice Location Address
First Line	:	2346 W CERMAK RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-3812
Country	:	US
Telephone Number	:	773-579-9480
Fax Number	:	773-579-9481

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DAI-HONG KIM
Credential	:	D.D.S
Telephone Number	:	347-534-8088

Provider Enumeration Date	:	09/23/2010
Last Update Date	:	09/23/2010

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