=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891122768
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEHIGH DENTAL CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/08/2013
-----------------------------------------------------
Last Update Date | 10/08/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6420 N LEHIGH AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60646-2704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-594-9115
-----------------------------------------------------
Fax | 773-594-9396
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6420 N LEHIGH AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60646-2704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-594-9115
-----------------------------------------------------
Fax | 773-594-9396
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DENTIST
-----------------------------------------------------
Name | DR. TATIANA S PAUNESCU
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 773-594-9115
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 019024077
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------