MEDICARE: HYDE PARK UNIVERSAL 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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1912248162
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HYDE PARK UNIVERSAL DENTAL LLC

Provider Business Mailing Address
First Line	:	1634 E 53RD ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60615-4384
Country	:	US
Telephone Number	:	773-966-6465
Fax Number	:	773-952-4683

Provider Business Practice Location Address
First Line	:	1634 E 53RD ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60615-4384
Country	:	US
Telephone Number	:	773-966-6465
Fax Number	:	773-952-4683

Authorized Official
Title or Position	:	OWNER
Name	:	AHMED RAMAHA
Credential	:	DDS
Telephone Number	:	773-966-6465

Provider Enumeration Date	:	03/13/2013
Last Update Date	:	03/13/2013

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