MEDICARE: DR. JAN NOWAK 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	1223E0200X	Endodontics		IL

General Provider Information

NPI Number	:	1538294087
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAN NOWAK D.D,S.

Provider Business Mailing Address
First Line	:	6143 N NORTHWEST HWY
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60631-2127
Country	:	US
Telephone Number	:	773-792-2369
Fax Number	:	773-792-2387

Provider Business Practice Location Address
First Line	:	6143 N NORTHWEST HWY
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60631-2127
Country	:	US
Telephone Number	:	773-792-2369
Fax Number	:	773-792-2387

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

Provider Enumeration Date	:	02/23/2007
Last Update Date	:	07/08/2007

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