MEDICARE: DR. JORDAN J TILDEN 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	19A14168	IL

General Provider Information

NPI Number	:	1194870899
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JORDAN J TILDEN DDS

Provider Business Mailing Address
First Line	:	333 E ONTARIO ST
Second Line	:	SUITE A
City	:	CHICAGO
State	:	IL
Zip	:	60611-4804
Country	:	US
Telephone Number	:	312-664-6616
Fax Number	:	312-664-0515

Provider Business Practice Location Address
First Line	:	333 E ONTARIO ST
Second Line	:	SUITE A
City	:	CHICAGO
State	:	IL
Zip	:	60611-4804
Country	:	US
Telephone Number	:	312-664-6616
Fax Number	:	312-664-0515

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

Provider Enumeration Date	:	01/24/2007
Last Update Date	:	07/08/2007

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