MEDICARE: MAXIME BOUVAGNET DMD

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	122300000X	Dentist	019034281	IL

General Provider Information

NPI Number	:	1295428803
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAXIME BOUVAGNET DMD

Provider Business Mailing Address
First Line	:	1541 W WELLINGTON AVE # G
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-4014
Country	:	US
Telephone Number	:	312-493-0956
Fax Number	:

Provider Business Practice Location Address
First Line	:	4641 W DIVERSEY AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60639-1828
Country	:	US
Telephone Number	:	773-692-4147
Fax Number	:

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

Provider Enumeration Date	:	05/30/2023
Last Update Date	:	05/30/2023

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