Provider Demographics
NPI:1700339173
Name:BAILEY, MARY (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:
Last Name:BAILEY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:GRANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:5160 S PULASKI RD STE 102
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60632-4253
Mailing Address - Country:US
Mailing Address - Phone:773-423-2810
Mailing Address - Fax:
Practice Address - Street 1:5160 S PULASKI RD
Practice Address - Street 2:SUITE 102
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60632-4253
Practice Address - Country:US
Practice Address - Phone:773-423-2810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-02
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019030849122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist