MEDICARE: DR. SHAUN ALEX 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	019.028030	IL

General Provider Information

NPI Number	:	1174751036
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHAUN ALEX D.D.S.

Provider Business Mailing Address
First Line	:	425 S ELMWOOD AVE
Second Line	:	3
City	:	OAK PARK
State	:	IL
Zip	:	60302-4015
Country	:	US
Telephone Number	:	202-321-8810
Fax Number	:

Provider Business Practice Location Address
First Line	:	3020 W MONTROSE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-1312
Country	:	US
Telephone Number	:	773-463-4800
Fax Number	:

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

Provider Enumeration Date	:	06/30/2009
Last Update Date	:	06/30/2009

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