MEDICARE: DR. LUKA BUNDALO DDS

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	019	IL
2	1223G0001X	General Practice Dentistry	6073	AZ

General Provider Information

NPI Number	:	1366609125
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LUKA BUNDALO DDS

Provider Business Mailing Address
First Line	:	2925 W TOUHY AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60645-2937
Country	:	US
Telephone Number	:	773-465-2600
Fax Number	:	773-465-2724

Provider Business Practice Location Address
First Line	:	2925 W TOUHY AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60645-2937
Country	:	US
Telephone Number	:	773-465-2600
Fax Number	:	773-465-2724

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

Provider Enumeration Date	:	05/20/2008
Last Update Date	:	05/20/2008

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