MEDICARE: DENTISTAS HISPANOS FOUNDATION FOR ORAL HEALTH CARE , 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	261QD0000X	Dental Clinic/Center	019.026594	IL

General Provider Information

NPI Number	:	1437309945
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTISTAS HISPANOS FOUNDATION FOR ORAL HEALTH CARE , P.C.

Provider Business Mailing Address
First Line	:	1520 CRAB TREE DR
Second Line	:
City	:	WESTMONT
State	:	IL
Zip	:	60559-3466
Country	:	US
Telephone Number	:	630-965-6326
Fax Number	:

Provider Business Practice Location Address
First Line	:	3622 W 26TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60623-3936
Country	:	US
Telephone Number	:	773-522-5252
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. GIANCARLO MALDONADO
Credential	:	D.D.S.
Telephone Number	:	630-965-6326

Provider Enumeration Date	:	09/22/2008
Last Update Date	:	09/22/2008

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