MEDICARE: CUSP DENTAL STUDIO PC

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	019-029332	IL
2	1223G0001X	General Practice Dentistry	019-030017	IL
3	1223G0001X	General Practice Dentistry	019-026174	IL

General Provider Information

NPI Number	:	1447706494
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CUSP DENTAL STUDIO PC

Provider Business Mailing Address
First Line	:	3917 N ASHLAND AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-5233
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3917 N ASHLAND AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-5233
Country	:	US
Telephone Number	:	773-687-8052
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	JACKIE JONES
Credential	:
Telephone Number	:	773-687-8052

Provider Enumeration Date	:	08/30/2016
Last Update Date	:	08/30/2016

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