MEDICARE: INNOVATIVE ENDODONTICS, 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	1223E0200X	Endodontics		IL

General Provider Information

NPI Number	:	1508035619
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNOVATIVE ENDODONTICS, P.C.

Provider Business Mailing Address
First Line	:	4346 N PULASKI RD # AB
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60641-2156
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4346 N PULASKI RD # AB
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60641-2156
Country	:	US
Telephone Number	:	773-544-1025
Fax Number	:	773-649-9282

Authorized Official
Title or Position	:	OWNER
Name	:	DR. REBECCA S PRESCOTT
Credential	:	DDS, MS
Telephone Number	:	773-544-1025

Provider Enumeration Date	:	02/22/2008
Last Update Date	:	02/22/2008

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