MEDICARE: SOFIA DENTAL

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	019028285	IL

General Provider Information

NPI Number	:	1558769190
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOFIA DENTAL

Provider Business Mailing Address
First Line	:	4413 N CLARK ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-5403
Country	:	US
Telephone Number	:	773-770-4766
Fax Number	:	773-770-4766

Provider Business Practice Location Address
First Line	:	4413 N CLARK ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-5403
Country	:	US
Telephone Number	:	773-770-4766
Fax Number	:	773-770-4766

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. SILVIA VALTCHEVA
Credential	:
Telephone Number	:	773-770-4766

Provider Enumeration Date	:	12/15/2014
Last Update Date	:	12/15/2014

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Directions to “SOFIA DENTAL ” Practice Location

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