=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487606950
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SCOTT LANCE TOMAR D.M.D., DR.P.H
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2006
-----------------------------------------------------
Last Update Date | 05/17/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 801 S PAULINA ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60612-7210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-413-7365
-----------------------------------------------------
Fax | 312-413-9050
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 801 S PAULINA ST # MC621
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60612-7210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-413-7365
-----------------------------------------------------
Fax | 312-413-9050
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223D0001X
-----------------------------------------------------
Taxonomy Name | Public Health Dentistry
-----------------------------------------------------
License Number | 019.032903
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------