MEDICARE: ISABELLA TERRASSA REYES DMD 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	019.029465	IL

General Provider Information

NPI Number	:	1457718215
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ISABELLA TERRASSA REYES DMD PC

Provider Business Mailing Address
First Line	:	100 W CHESTNUT ST
Second Line	:	APT. 1008
City	:	CHICAGO
State	:	IL
Zip	:	60610-3225
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 W CHESTNUT ST
Second Line	:	APT. 1008
City	:	CHICAGO
State	:	IL
Zip	:	60610-3225
Country	:	US
Telephone Number	:	939-475-6629
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ISABELLA TERRASSA REYES
Credential	:	D.M.D.
Telephone Number	:	939-475-6629

Provider Enumeration Date	:	01/25/2016
Last Update Date	:	01/25/2016

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