MEDICARE: DR. WAEIL ELMISALATI DDS, MMEDSC

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	019.030426	IL
2	1223P0300X	Periodontics	021002903	IL

General Provider Information

NPI Number	:	1538430590
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WAEIL ELMISALATI DDS, MMEDSC

Provider Business Mailing Address
First Line	:	415 HOWARD ST APT 1612
Second Line	:
City	:	EVANSTON
State	:	IL
Zip	:	60202-4056
Country	:	US
Telephone Number	:	617-953-0266
Fax Number	:	617-432-4258

Provider Business Practice Location Address
First Line	:	2335 W FULLERTON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-3225
Country	:	US
Telephone Number	:	617-953-0266
Fax Number	:

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

Provider Enumeration Date	:	01/23/2012
Last Update Date	:	10/24/2019

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