Organization
MT. GREENWOOD DENTAL CLINIC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. KENNETH BROCKER D.D.S. (OWNER)
(773) 238-4451
Entity
Organization
Contact information
Practice address
3135 W 111TH ST, CHICAGO, IL 60655-2223
(773) 238-4451
Mailing address
3135 W 111TH ST, CHICAGO, IL 60655-2223
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
019016104
IL
Other
Enumeration date
03/29/2012
Last updated
03/29/2012
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