=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124674106
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JULIANNA P SHAMOON DMD PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2019
-----------------------------------------------------
Last Update Date | 08/14/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1624 W DIVISION ST STE B
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60622-3908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-697-9796
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18W070 ROYCE BLVD APT 428
-----------------------------------------------------
City | OAKBROOK TERRACE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60181-4916
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-919-8123
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PERIODONTIST
-----------------------------------------------------
Name | DR. JULIANNNA SHAMOON
-----------------------------------------------------
Credential | D.M.D.
-----------------------------------------------------
Telephone | 810-919-8123
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------