MEDICARE: DR. TRINA MARIE BLUNT D.D.S.

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	1223D0001X	Public Health Dentistry		IL

General Provider Information

NPI Number	:	1518956978
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TRINA MARIE BLUNT D.D.S.

Provider Business Mailing Address
First Line	:	8100 S LUELLA AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60617-1152
Country	:	US
Telephone Number	:	217-202-5634
Fax Number	:	217-351-5104

Provider Business Practice Location Address
First Line	:	8100 S LUELLA AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60617-1152
Country	:	US
Telephone Number	:	217-202-5634
Fax Number	:	217-351-5104

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

Provider Enumeration Date	:	10/18/2005
Last Update Date	:	07/08/2007

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