=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134400831
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DEVON DENTAL CLINIC,LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2011
-----------------------------------------------------
Last Update Date | 10/06/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6259 N MILWAUKEE AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60646-3735
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-631-6607
-----------------------------------------------------
Fax | 773-631-9745
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6259 N MILWAUKEE AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60646-3735
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-631-6607
-----------------------------------------------------
Fax | 773-631-9745
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. HALINA TERESA LECH
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 773-631-6607
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 019-023650
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------