MEDICARE: F L M DENTAL CORP 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
1	1223G0001X	General Practice Dentistry	019027020	IL
2	1223G0001X	General Practice Dentistry	019020112	IL

General Provider Information

NPI Number	:	1235209727
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	F L M DENTAL CORP PC

Provider Business Mailing Address
First Line	:	3514 N LINCOLN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-1104
Country	:	US
Telephone Number	:	773-929-4140
Fax Number	:	773-929-2514

Provider Business Practice Location Address
First Line	:	3514 N LINCOLN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-1104
Country	:	US
Telephone Number	:	773-929-4140
Fax Number	:	773-929-2514

Authorized Official
Title or Position	:	OWNER
Name	:	JOSE MARISCAL
Credential	:
Telephone Number	:	773-929-4140

Provider Enumeration Date	:	11/09/2006
Last Update Date	:	02/21/2018

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Directions to “F L M DENTAL CORP PC ” Practice Location

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