=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083026652
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DUDA DENTAL ASSOCIATES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/29/2014
-----------------------------------------------------
Last Update Date | 05/29/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 534 GREEN BAY RD
-----------------------------------------------------
City | KENILWORTH
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60043-1801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-251-5136
-----------------------------------------------------
Fax | 847-251-1365
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 534 GREEN BAY RD
-----------------------------------------------------
City | KENILWORTH
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60043-1801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-251-5136
-----------------------------------------------------
Fax | 847-251-1365
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MS. YVONNE IZQUIERDO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 847-251-5136
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 019028318
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 19017946
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------