Healthcare Provider Details

I. General information

NPI: 1215429360
Provider Name (Legal Business Name): JUSTINE MARIA BEDNARSKI DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2018
Last Update Date: 07/07/2023
Certification Date: 06/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 W FULTON ST
CHICAGO IL
60607
US

IV. Provider business mailing address

1856 WEBSTER LN
DES PLAINES IL
60018-2059
US

V. Phone/Fax

Practice location:
  • Phone: 847-962-5175
  • Fax:
Mailing address:
  • Phone: 847-962-5175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019034103
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN1857937
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: