MEDICARE: FRATMISHIN JOHN ALEXANDER DMD

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		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104864297
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FRATMISHIN JOHN ALEXANDER DMD

Provider Business Mailing Address
First Line	:	6408 N CALIFORNIA AVE
Second Line	:	PO BOX 597770
City	:	CHICAGO
State	:	IL
Zip	:	60645-5209
Country	:	US
Telephone Number	:	773-338-6565
Fax Number	:	773-338-6552

Provider Business Practice Location Address
First Line	:	6408 N CALIFORNIA AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60645-5209
Country	:	US
Telephone Number	:	773-338-6565
Fax Number	:	773-338-6552

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

Provider Enumeration Date	:	06/02/2006
Last Update Date	:	07/08/2007

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