MEDICARE: BLUE STAR DENTAL INC

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	019030349	IL

General Provider Information

NPI Number	:	1144765777
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUE STAR DENTAL INC

Provider Business Mailing Address
First Line	:	5711 N KIMBALL AVE
Second Line	:	APT 1N
City	:	CHICAGO
State	:	IL
Zip	:	60659-4523
Country	:	US
Telephone Number	:	773-698-5773
Fax Number	:

Provider Business Practice Location Address
First Line	:	4703 W LAWRENCE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60630-1722
Country	:	US
Telephone Number	:	773-698-5773
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DORINA NASTASE
Credential	:	DMD
Telephone Number	:	773-698-5773

Provider Enumeration Date	:	01/06/2017
Last Update Date	:	01/06/2017

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