MEDICARE: NEIL R. B. BONJE 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	1223E0200X	Endodontics		IL

General Provider Information

NPI Number	:	1447328521
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NEIL R. B. BONJE DDS

Provider Business Mailing Address
First Line	:	9933 S WESTERN AVE
Second Line	:	SUITE 203
City	:	CHICAGO
State	:	IL
Zip	:	60643-1810
Country	:	US
Telephone Number	:	773-779-3636
Fax Number	:	773-779-3638

Provider Business Practice Location Address
First Line	:	9933 S WESTERN AVE
Second Line	:	SUITE 203
City	:	CHICAGO
State	:	IL
Zip	:	60643-1810
Country	:	US
Telephone Number	:	773-779-3636
Fax Number	:	773-779-3638

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

Provider Enumeration Date	:	11/30/2006
Last Update Date	:	07/08/2007

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