MEDICARE: CARLOS SALLIS DDS

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	122300000X	Dentist	19017265	IL

General Provider Information

NPI Number	:	1477610574
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLOS SALLIS DDS

Provider Business Mailing Address
First Line	:	623 AVENUE OF THE CITIES
Second Line	:
City	:	EAST MOLINE
State	:	IL
Zip	:	61244-4029
Country	:	US
Telephone Number	:	309-752-0350
Fax Number	:

Provider Business Practice Location Address
First Line	:	623 AVENUE OF THE CITIES
Second Line	:
City	:	EAST MOLINE
State	:	IL
Zip	:	61244-4029
Country	:	US
Telephone Number	:	309-752-0350
Fax Number	:

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

Provider Enumeration Date	:	01/02/2007
Last Update Date	:	07/08/2007

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