MEDICARE: DR. LOYOLA M. GLEASON D.D.S.

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	1223P0300X	Periodontics		IL

General Provider Information

NPI Number	:	1700915105
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LOYOLA M. GLEASON D.D.S.

Provider Business Mailing Address
First Line	:	1421 ROYAL OAK LN
Second Line	:
City	:	GLENVIEW
State	:	IL
Zip	:	60025-3162
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5945 S PULASKI RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60629-4550
Country	:	US
Telephone Number	:	773-776-5905
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/04/2007
Last Update Date	:	07/08/2007

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