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NPI Code Detail

MEDICARE: HOWARD L BLIVAISS DDS AND ASSOCIATES PC

MEDICARE: HOWARD L BLIVAISS DDS AND ASSOCIATES PC
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
1261QD0000XDental Clinic/CenterIL

General Provider Information

NPI Number : 1154481182
Entity Type Code : Organization
Provider Name (Legal Business Name) : HOWARD L BLIVAISS DDS AND ASSOCIATES PC
Provider Business Mailing Address
First Line : 3500 W PETERSON AVE
Second Line : SUITE 200
City : CHICAGO
State : IL
Zip : 60659-3306
Country : US
Telephone Number : 773-509-1234
Fax Number : 773-509-0495
Provider Business Practice Location Address
First Line : 3500 W PETERSON AVE
Second Line : SUITE 200
City : CHICAGO
State : IL
Zip : 60659-3306
Country : US
Telephone Number : 773-509-1234
Fax Number : 773-509-0495
Authorized Official
Title or Position : PRESIDENT
Name : DR. HOWARD L BLIVAISS
Credential : DDS
Telephone Number : 773-509-1234
Provider Enumeration Date : 12/11/2006
Last Update Date : 08/22/2020

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