Healthcare Provider Details

I. General information

NPI: 1386203164
Provider Name (Legal Business Name): MARY ELIZABETH HYDES DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2019
Last Update Date: 07/21/2022
Certification Date: 07/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8410 S HOLLAND RD
CHICAGO IL
60620-6062
US

IV. Provider business mailing address

2801 N WOLCOTT AVE UNIT O
CHICAGO IL
60657-4159
US

V. Phone/Fax

Practice location:
  • Phone: 773-420-1267
  • Fax:
Mailing address:
  • Phone: 954-296-8565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019032192
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: