Healthcare Provider Details

I. General information

NPI: 1851590582
Provider Name (Legal Business Name): MICHAEL BUKUMIRA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2007
Last Update Date: 07/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2358 N LINCOLN AVE
CHICAGO IL
60614-3321
US

IV. Provider business mailing address

2358 N LINCOLN AVE
CHICAGO IL
60614-3321
US

V. Phone/Fax

Practice location:
  • Phone: 773-327-4442
  • Fax: 773-327-7725
Mailing address:
  • Phone: 773-327-4442
  • Fax: 773-327-7725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: