=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871026724
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BO YEON BARTILOTTA DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/07/2017
-----------------------------------------------------
Last Update Date | 10/02/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11585 US-14
-----------------------------------------------------
City | WOODSTOCK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60098
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-242-1019
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 THORNDALE CT
-----------------------------------------------------
City | SOUTH ELGIN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60177-3202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-241-0475
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 019.031238
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------