Provider Demographics
NPI:1851896286
Name:BEDMUTHA, KETAN S (DMD)
Entity Type:Individual
Prefix:
First Name:KETAN
Middle Name:S
Last Name:BEDMUTHA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 W JACKSON BLVD UNIT 1404
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60661-5642
Mailing Address - Country:US
Mailing Address - Phone:716-725-1593
Mailing Address - Fax:
Practice Address - Street 1:1950 W CERMAK RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-4204
Practice Address - Country:US
Practice Address - Phone:773-376-2777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-27
Last Update Date:2021-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0320661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty