MEDICARE: CRESTWOOD DENTAL AND TMJ CARE 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	332BC3200X	Customized Equipment (DME)		IL
2	122300000X	Dentist	019024802	IL

General Provider Information

NPI Number	:	1730556101
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRESTWOOD DENTAL AND TMJ CARE PC

Provider Business Mailing Address
First Line	:	13549 CICERO AVE
Second Line	:
City	:	CRESTWOOD
State	:	IL
Zip	:	60445-1934
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	13549 CICERO AVE
Second Line	:
City	:	CRESTWOOD
State	:	IL
Zip	:	60445-1934
Country	:	US
Telephone Number	:	708-388-3200
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. KEVIN BARGAMIAN
Credential	:
Telephone Number	:	708-388-3200

Provider Enumeration Date	:	09/01/2015
Last Update Date	:	08/08/2016

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