MEDICARE: BRIDGEPORT DENTAL SPECIALISTS LLC

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	019027652	IL

General Provider Information

NPI Number	:	1932416898
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIDGEPORT DENTAL SPECIALISTS LLC

Provider Business Mailing Address
First Line	:	2959 S WALLACE ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616-3034
Country	:	US
Telephone Number	:	312-791-0920
Fax Number	:	312-842-5338

Provider Business Practice Location Address
First Line	:	2959 S WALLACE ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616-3034
Country	:	US
Telephone Number	:	312-791-0920
Fax Number	:	312-842-5338

Authorized Official
Title or Position	:	OWNER
Name	:	DR. STEVEN VONGLUEKIAT
Credential	:
Telephone Number	:	312-791-0920

Provider Enumeration Date	:	09/13/2010
Last Update Date	:	09/13/2010

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