MEDICARE: CHICAGO LAKE FAMILY DENTAL LLC

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1770095028
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHICAGO LAKE FAMILY DENTAL LLC

Provider Business Mailing Address
First Line	:	4893 BOATMAN LN
Second Line	:
City	:	INVER GROVE HEIGHTS
State	:	MN
Zip	:	55076-1160
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2900 CHICAGO AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55407-1322
Country	:	US
Telephone Number	:	612-823-2080
Fax Number	:

Authorized Official
Title or Position	:	GENERAL DENTIST
Name	:	DR. ALI BARBARAWI
Credential	:	DMD
Telephone Number	:	612-823-2080

Provider Enumeration Date	:	10/26/2017
Last Update Date	:	10/26/2017

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