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General NPI Number Information
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NPI Number | 1437309945
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Entity Type | Organization
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Legal Business Name | DENTISTAS HISPANOS FOUNDATION FOR ORAL HEALTH CARE , P.C.
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Dates
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Enumeration Date | 09/22/2008
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Last Update Date | 09/22/2008
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Provider Practice Location Address
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Address Line | 3622 W 26TH ST
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City | CHICAGO
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State | IL
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Zip | 60623-3936
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Country | US
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Telephone | 773-522-5252
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Fax |
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Provider Business Mailing Address
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Address Line | 1520 CRAB TREE DR
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City | WESTMONT
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State | IL
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Zip | 60559-3466
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Country | US
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Telephone | 630-965-6326
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | DR. GIANCARLO MALDONADO
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Credential | D.D.S.
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Telephone | 630-965-6326
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 019.026594
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License Number State | IL
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