MEDICARE: DR. MICHAELA RENEE CAVENDER DMD

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	1223G0001X	General Practice Dentistry	019035174	IL

General Provider Information

NPI Number	:	1982446050
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAELA RENEE CAVENDER DMD

Provider Business Mailing Address
First Line	:	4961 N GRANDVIEW DR
Second Line	:
City	:	PEORIA HEIGHTS
State	:	IL
Zip	:	61616-5372
Country	:	US
Telephone Number	:	630-589-2683
Fax Number	:

Provider Business Practice Location Address
First Line	:	210 N 4TH ST
Second Line	:
City	:	CHILLICOTHEE
State	:	IL
Zip	:	61523-2058
Country	:	US
Telephone Number	:	309-274-3820
Fax Number	:	866-309-7302

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

Provider Enumeration Date	:	06/10/2024
Last Update Date	:	06/10/2024

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