MEDICARE: CHICAGO OSTEOPATHIC HOSPITAL DENTAL CLINIC, P.C.

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	019022626	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1699868364
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHICAGO OSTEOPATHIC HOSPITAL DENTAL CLINIC, P.C.

Provider Business Mailing Address
First Line	:	1525 E. 53RD ST.
Second Line	:	#522
City	:	CHICAGO
State	:	IL
Zip	:	60615-4530
Country	:	US
Telephone Number	:	773-947-4665
Fax Number	:	773-256-2373

Provider Business Practice Location Address
First Line	:	1525 E. 53RD ST.
Second Line	:	#522
City	:	CHICAGO
State	:	IL
Zip	:	60615-4530
Country	:	US
Telephone Number	:	773-947-4665
Fax Number	:	773-256-2373

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MS. ANA C HERNANDEZ
Credential	:
Telephone Number	:	773-947-4665

Provider Enumeration Date	:	10/02/2006
Last Update Date	:	06/11/2008

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