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General NPI Number Information
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NPI Number | 1851785224
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Entity Type | Organization
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Legal Business Name | FLOSS DENTAL STUDIO PC
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Dates
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Enumeration Date | 03/24/2015
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Last Update Date | 04/23/2015
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Provider Practice Location Address
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Address Line | 924 N DAMEN AVE
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City | CHICAGO
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State | IL
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Zip | 60622-4948
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Country | US
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Telephone | 773-235-2322
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Fax | 773-235-2332
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Provider Business Mailing Address
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Address Line | PO BOX 221018
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City | CHICAGO
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State | IL
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Zip | 60622-0008
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Country | US
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Telephone | 773-235-2322
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Fax | 773-235-2332
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Authorized Official
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Title or Position | OWNER/PRES/DENTIST
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Name | DR. MICHELLE ANN RADEKA
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Credential | DMD
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Telephone | 773-235-2322
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332BC3200X
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Taxonomy Name | Customized Equipment (DME)
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019025071
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License Number State | IL
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