MEDICARE: MICHELE T BOGACKI DDS, LTD.

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	261QD0000X	Dental Clinic/Center		IL

General Provider Information

NPI Number	:	1528081965
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MICHELE T BOGACKI DDS, LTD.

Provider Business Mailing Address
First Line	:	4452 N CENTRAL AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60630-3302
Country	:	US
Telephone Number	:	773-777-4800
Fax Number	:	773-777-4918

Provider Business Practice Location Address
First Line	:	4452 N CENTRAL AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60630-3302
Country	:	US
Telephone Number	:	773-777-4800
Fax Number	:	773-777-4918

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MICHELE T. BOGACKI
Credential	:	D.D.S.
Telephone Number	:	773-777-4800

Provider Enumeration Date	:	07/26/2006
Last Update Date	:	08/22/2020

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