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NPI Code Detail

MEDICARE: DR. HOWARD L BLIVAISS DDS

MEDICARE: DR. HOWARD L BLIVAISS DDS
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
11223G0001XGeneral Practice DentistryIL

General Provider Information

NPI Number : 1922168954
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. HOWARD L BLIVAISS DDS
Provider Business Mailing Address
First Line : 3500 W PETERSON AVE
Second Line : SUITE 200
City : CHICAGO
State : IL
Zip : 60659-3306
Country : US
Telephone Number : 773-509-1234
Fax Number : 773-509-0495
Provider Business Practice Location Address
First Line : 3500 W PETERSON AVE
Second Line : SUITE 200
City : CHICAGO
State : IL
Zip : 60659-3306
Country : US
Telephone Number : 773-509-1234
Fax Number : 773-509-0495
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/11/2006
Last Update Date : 07/08/2007

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