MEDICARE: EMILIYA TANEVA

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	018001794	IL
2	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	019029752	IL
3	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	021002588	IL

General Provider Information

NPI Number	:	1205256906
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMILIYA TANEVA

Provider Business Mailing Address
First Line	:	73 E LAKE ST APT 3508
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60601-4800
Country	:	US
Telephone Number	:	312-504-7972
Fax Number	:

Provider Business Practice Location Address
First Line	:	73 E LAKE ST APT 3508
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60601-4800
Country	:	US
Telephone Number	:	312-504-7972
Fax Number	:

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

Provider Enumeration Date	:	04/21/2014
Last Update Date	:	12/16/2014

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Directions to “ EMILIYA TANEVA ” Practice Location

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