MEDICARE: BUCKTOWN WICKER PARK DENTAL

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1982049748
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BUCKTOWN WICKER PARK DENTAL

Provider Business Mailing Address
First Line	:	2303 W NORTH AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-5314
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2303 W NORTH AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-5314
Country	:	US
Telephone Number	:	773-252-2303
Fax Number	:

Authorized Official
Title or Position	:	RECEPTIONIST
Name	:	MONICA MARTINEZ
Credential	:
Telephone Number	:	773-252-2303

Provider Enumeration Date	:	05/07/2013
Last Update Date	:	05/07/2013

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