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NPI Code Detail

MEDICARE: FULLSMILE FAMILY DENTIST

MEDICARE: FULLSMILE FAMILY DENTIST
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
11223G0001XGeneral Practice Dentistry019024678IL

General Provider Information

NPI Number : 1316110547
Entity Type Code : Organization
Provider Name (Legal Business Name) : FULLSMILE FAMILY DENTIST
Provider Business Mailing Address
First Line : 3939 W FULLERTON AVE
Second Line :
City : CHICAGO
State : IL
Zip : 60647-2243
Country : US
Telephone Number : 773-235-0000
Fax Number : 773-235-0001
Provider Business Practice Location Address
First Line : 3939 W FULLERTON AVE
Second Line :
City : CHICAGO
State : IL
Zip : 60647-2243
Country : US
Telephone Number : 773-235-0000
Fax Number : 773-235-0001
Authorized Official
Title or Position : DENTIST
Name : MR. EDISON ALBERT ISHAYA
Credential :
Telephone Number : 773-235-0000
Provider Enumeration Date : 04/09/2008
Last Update Date : 05/02/2008

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Directions to “FULLSMILE FAMILY DENTIST ” Practice Location

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These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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