MEDICARE: DR. MARMAR MODARRESSI DDS, MS

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	019.028205	IL

General Provider Information

NPI Number	:	1699973636
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARMAR MODARRESSI DDS, MS

Provider Business Mailing Address
First Line	:	845 N MICHIGAN AVE STE 940W
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60611-2216
Country	:	US
Telephone Number	:	312-751-1020
Fax Number	:	312-751-1231

Provider Business Practice Location Address
First Line	:	845 N MICHIGAN AVE STE 940W
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60611-2216
Country	:	US
Telephone Number	:	312-751-1020
Fax Number	:

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

Provider Enumeration Date	:	07/10/2007
Last Update Date	:	04/10/2024

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