Healthcare Provider Details

I. General information

NPI: 1760638159
Provider Name (Legal Business Name): PAUL BUENVENIDA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2008
Last Update Date: 05/03/2021
Certification Date: 05/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 E WASHINGTON ST 3001
CHICAGO IL
60602-2103
US

IV. Provider business mailing address

3750 N LAKE SHORE DR APT 13C
CHICAGO IL
60613-4229
US

V. Phone/Fax

Practice location:
  • Phone: 312-407-9900
  • Fax:
Mailing address:
  • Phone: 708-400-2169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019023430
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: