MEDICARE: DR. IRVIN BRUNO WATKINS D.D.S

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	1223G0001X	General Practice Dentistry	19A14703	IL

General Provider Information

NPI Number	:	1033359674
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. IRVIN BRUNO WATKINS D.D.S

Provider Business Mailing Address
First Line	:	1411 E. 53RD STREET
Second Line	:	2ND FLOOR
City	:	CHICAGO
State	:	IL
Zip	:	60615-4542
Country	:	US
Telephone Number	:	773-752-1234
Fax Number	:	773-752-4321

Provider Business Practice Location Address
First Line	:	1411 E. 53RD STREET
Second Line	:	2ND FLOOR
City	:	CHICAGO
State	:	IL
Zip	:	60615-4542
Country	:	US
Telephone Number	:	773-752-1234
Fax Number	:	773-752-4321

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/23/2009
Last Update Date	:	02/23/2009

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