MEDICARE: ATHENA DENTAL INSTITUTE P C

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	019022059	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1427580075
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ATHENA DENTAL INSTITUTE P C

Provider Business Mailing Address
First Line	:	1621 W NORTH AVE
Second Line	:	UNIT C-1
City	:	CHICAGO
State	:	IL
Zip	:	60622-2328
Country	:	US
Telephone Number	:	773-235-2000
Fax Number	:

Provider Business Practice Location Address
First Line	:	1621 W NORTH AVE
Second Line	:	UNIT C-1
City	:	CHICAGO
State	:	IL
Zip	:	60622-2328
Country	:	US
Telephone Number	:	773-235-2000
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ANDREA MILLER-FINCH
Credential	:	DDS
Telephone Number	:	773-235-2000

Provider Enumeration Date	:	04/03/2017
Last Update Date	:	04/03/2017

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