=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013414655
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | FLAVIO JOSE CASTELLI SANCHEZ BDS, MS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2018
-----------------------------------------------------
Last Update Date | 04/10/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 801 S PAULINA ST RM 131
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60612-7210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-523-9228
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1244 W MONROE ST UNIT 9
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60607-2572
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-523-9228
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 136000222
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------