MEDICARE: SARAH A WOLOSZCZUK

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	124Q00000X	Dental Hygienist	020015153	IL

General Provider Information

NPI Number	:	1316323488
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SARAH A WOLOSZCZUK

Provider Business Mailing Address
First Line	:	5806 SHERMAN AVE
Second Line	:
City	:	DOWNERS GROVE
State	:	IL
Zip	:	60516-1166
Country	:	US
Telephone Number	:	630-297-5874
Fax Number	:

Provider Business Practice Location Address
First Line	:	1601 N HARLEM AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60707-4303
Country	:	US
Telephone Number	:	773-745-3301
Fax Number	:

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

Provider Enumeration Date	:	07/30/2015
Last Update Date	:	10/07/2016

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