MEDICARE: DENTAL SHINE II, P, C.

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	019026154	IL

General Provider Information

NPI Number	:	1790923274
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL SHINE II, P, C.

Provider Business Mailing Address
First Line	:	4719 S KEDZIE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60632-3001
Country	:	US
Telephone Number	:	773-847-4444
Fax Number	:

Provider Business Practice Location Address
First Line	:	4719 S KEDZIE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60632-3001
Country	:	US
Telephone Number	:	773-847-4444
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. FIRAS FALEH EL-MUQDAD
Credential	:
Telephone Number	:	773-847-4444

Provider Enumeration Date	:	01/22/2009
Last Update Date	:	01/22/2009

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