MEDICARE: MISS VANESSA CAMPOS

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	124Q00000X	Dental Hygienist	020014796	IL
2	124Q00000X	Dental Hygienist	13007774A	IN

General Provider Information

NPI Number	:	1467903393
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS VANESSA CAMPOS

Provider Business Mailing Address
First Line	:	1752 N TAFT AVE
Second Line	:
City	:	BERKELEY
State	:	IL
Zip	:	60163-1555
Country	:	US
Telephone Number	:	708-449-8683
Fax Number	:

Provider Business Practice Location Address
First Line	:	1752 N TAFT AVE
Second Line	:
City	:	BERKELEY
State	:	IL
Zip	:	60163-1555
Country	:	US
Telephone Number	:	708-449-8683
Fax Number	:

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

Provider Enumeration Date	:	10/14/2016
Last Update Date	:	11/01/2016

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Directions to “ MISS VANESSA CAMPOS ” Practice Location

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