MEDICARE: MINATI MUKHERJEE 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	122300000X	Dentist		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1003068	OTHER	IL	PROVIDER ID NUMBER

General Provider Information

NPI Number	:	1912996919
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MINATI MUKHERJEE D.D.S., M.S.

Provider Business Mailing Address
First Line	:	2720 W 15TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-1610
Country	:	US
Telephone Number	:	773-257-6485
Fax Number	:

Provider Business Practice Location Address
First Line	:	2720 W 15TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-1610
Country	:	US
Telephone Number	:	773-257-6485
Fax Number	:

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

Provider Enumeration Date	:	10/21/2005
Last Update Date	:	07/08/2007

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