Healthcare Provider Details

I. General information

NPI: 1306264163
Provider Name (Legal Business Name): PIOTR BARYSENKA D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2014
Last Update Date: 03/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 N MICHIGAN AVE APT 2217
CHICAGO IL
60601-7506
US

IV. Provider business mailing address

151 N MICHIGAN AVE APT 2217
CHICAGO IL
60601-7506
US

V. Phone/Fax

Practice location:
  • Phone: 818-406-9898
  • Fax:
Mailing address:
  • Phone: 818-406-9898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number019029451
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number021002678
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: