MEDICARE: DR. NANDINI TUMKUR SUBBARAJU 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	1917344	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	101292	OTHER	IL	DORAL ID #

General Provider Information

NPI Number	:	1417946872
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NANDINI TUMKUR SUBBARAJU D.D.S

Provider Business Mailing Address
First Line	:	1950 W CERMAK RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-4204
Country	:	US
Telephone Number	:	773-376-2777
Fax Number	:	773-376-2736

Provider Business Practice Location Address
First Line	:	1950 W CERMAK RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-4204
Country	:	US
Telephone Number	:	773-376-2777
Fax Number	:	773-376-2736

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

Provider Enumeration Date	:	10/18/2005
Last Update Date	:	07/08/2007

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