MEDICARE: DR. MYTHILI RAJESH BDS, MS

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	019.029199	IL

General Provider Information

NPI Number	:	1346598406
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MYTHILI RAJESH BDS, MS

Provider Business Mailing Address
First Line	:	804 POMEROON ST
Second Line	:	APT# 207
City	:	NAPERVILLE
State	:	IL
Zip	:	60540-4882
Country	:	US
Telephone Number	:	205-356-7326
Fax Number	:

Provider Business Practice Location Address
First Line	:	3020 W MONTROSE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-1312
Country	:	US
Telephone Number	:	773-754-3900
Fax Number	:

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

Provider Enumeration Date	:	08/21/2012
Last Update Date	:	08/21/2012

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