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General NPI Number Information
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NPI Number | 1285705186
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Entity Type | Individual
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Provider Name | AMY MARIE VANFOSSEN DDS
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Gender | Female
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Dates
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Enumeration Date | 11/13/2006
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Last Update Date | 10/28/2014
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Provider Practice Location Address
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Address Line | 25 E WASHINGTON ST SUITE 1211
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City | CHICAGO
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State | IL
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Zip | 60602-1708
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Country | US
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Telephone | 312-263-5090
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Fax |
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Provider Business Mailing Address
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Address Line | 25 E WASHINGTON ST SUITE 1211 (NEW SUITE NUMBER)
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City | CHICAGO
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State | IL
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Zip | 60602-1708
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Country | US
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Telephone | 312-264-5090
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019026405
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License Number State | IL
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