MEDICARE: DR. GIANCARLO MALDONADO D.D.S.

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	019-026594	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1437309945	OTHER	IL	TYPE 2 NPI

General Provider Information

NPI Number	:	1184877524
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GIANCARLO MALDONADO D.D.S.

Provider Business Mailing Address
First Line	:	1520 CRAB TREE DR
Second Line	:
City	:	WESTMONT
State	:	IL
Zip	:	60559-3466
Country	:	US
Telephone Number	:	630-965-6326
Fax Number	:

Provider Business Practice Location Address
First Line	:	3622 W 26TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60623-3936
Country	:	US
Telephone Number	:	773-522-5252
Fax Number	:	773-522-0509

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/29/2008
Last Update Date	:	10/29/2008

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