=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073032967
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JORDAN ANNE BRETSCH DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2017
-----------------------------------------------------
Last Update Date | 09/12/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | CAPTAIN JAMES A. LOVELL FEDERAL HEALTH CARE CENTER 3001 GREEN BAY ROAD
-----------------------------------------------------
City | NORTH CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60064
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-688-1900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 365 N HALSTED ST APT 2916
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60661-1379
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 019.031400
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------