MEDICARE: DR. LION GRENADER DMD

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	019031298	IL

General Provider Information

NPI Number	:	1720501380
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LION GRENADER DMD

Provider Business Mailing Address
First Line	:	400 PENNY LN
Second Line	:
City	:	GRAYSLAKE
State	:	IL
Zip	:	60030-3737
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	644 SHERIDAN RD # D
Second Line	:
City	:	WINTHROP HARBOR
State	:	IL
Zip	:	60096-1350
Country	:	US
Telephone Number	:	847-872-5626
Fax Number	:

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

Provider Enumeration Date	:	07/25/2017
Last Update Date	:	03/17/2018

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