Healthcare Provider Details

I. General information

NPI: 1477112043
Provider Name (Legal Business Name): PRATISHTHA MISHRA BDS, MDS, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2019
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 S PAULINA ST
CHICAGO IL
60612-7210
US

IV. Provider business mailing address

801 S PAULINA ST
CHICAGO IL
60612-7210
US

V. Phone/Fax

Practice location:
  • Phone: 312-355-1229
  • Fax:
Mailing address:
  • Phone: 312-996-7555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X2210X
TaxonomyOrofacial Pain Dentistry
License Number136.000287
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number136.000287
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: