MEDICARE: PORTAGE PARK DENTAL ASSOCIATES, LTD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	019026570	IL

General Provider Information

NPI Number	:	1003124371
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PORTAGE PARK DENTAL ASSOCIATES, LTD

Provider Business Mailing Address
First Line	:	5613 W IRVING PARK RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60634-2740
Country	:	US
Telephone Number	:	773-286-4030
Fax Number	:	773-736-0716

Provider Business Practice Location Address
First Line	:	5613 W IRVING PARK RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60634-2740
Country	:	US
Telephone Number	:	773-286-4030
Fax Number	:	773-736-0716

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ANETA CHOMA-DLOUCHY
Credential	:	DDS
Telephone Number	:	773-286-4030

Provider Enumeration Date	:	09/20/2010
Last Update Date	:	09/20/2010

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