MEDICARE: RAQUEL MIRANDA PORTUGAL 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		IL

General Provider Information

NPI Number	:	1598821225
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RAQUEL MIRANDA PORTUGAL D.D.S.

Provider Business Mailing Address
First Line	:	2424 W FULLERTON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-3155
Country	:	US
Telephone Number	:	773-384-8823
Fax Number	:	773-384-8811

Provider Business Practice Location Address
First Line	:	2424 W FULLERTON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-3155
Country	:	US
Telephone Number	:	773-384-8823
Fax Number	:	773-384-8811

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

Provider Enumeration Date	:	12/28/2006
Last Update Date	:	07/08/2007

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