MEDICARE: DR. MARIA G PATINO D.D.S, M.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	1223P0300X	Periodontics	019-026187	IL

General Provider Information

NPI Number	:	1669489118
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARIA G PATINO D.D.S, M.S.

Provider Business Mailing Address
First Line	:	125 E 13TH ST
Second Line	:	UNIT 1405
City	:	CHICAGO
State	:	IL
Zip	:	60605-2655
Country	:	US
Telephone Number	:	312-834-0521
Fax Number	:

Provider Business Practice Location Address
First Line	:	1411 W IRVING PARK RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-1920
Country	:	US
Telephone Number	:	773-404-8030
Fax Number	:

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

Provider Enumeration Date	:	08/01/2006
Last Update Date	:	07/08/2007

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