MEDICARE: DR. ROGOBERTO ULLOA DDS

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	19026192	IL

General Provider Information

NPI Number	:	1114016573
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROGOBERTO ULLOA DDS

Provider Business Mailing Address
First Line	:	500 N CHICAGO ST
Second Line	:
City	:	JOLIET
State	:	IL
Zip	:	60432-1706
Country	:	US
Telephone Number	:	815-724-0500
Fax Number	:	815-724-0583

Provider Business Practice Location Address
First Line	:	500 N CHICAGO ST
Second Line	:
City	:	JOLIET
State	:	IL
Zip	:	60432-1706
Country	:	US
Telephone Number	:	815-724-0500
Fax Number	:	815-724-0583

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

Provider Enumeration Date	:	10/12/2006
Last Update Date	:	07/08/2007

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