MEDICARE: KEY DENTAL 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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1720740574
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KEY DENTAL PC

Provider Business Mailing Address
First Line	:	1606 W CAMPBELL ST
Second Line	:
City	:	ARLINGTON HEIGHTS
State	:	IL
Zip	:	60005-1516
Country	:	US
Telephone Number	:	847-255-8439
Fax Number	:	847-255-8770

Provider Business Practice Location Address
First Line	:	1606 W CAMPBELL ST
Second Line	:
City	:	ARLINGTON HEIGHTS
State	:	IL
Zip	:	60005-1516
Country	:	US
Telephone Number	:	847-255-8439
Fax Number	:	847-255-8770

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MATTHEW GOTTA
Credential	:	DMD
Telephone Number	:	224-330-5390

Provider Enumeration Date	:	10/08/2021
Last Update Date	:	10/08/2021

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