MEDICARE: BRISTLE DENTAL STUDIO

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	1223G0001X	General Practice Dentistry
2	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1578246930
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRISTLE DENTAL STUDIO

Provider Business Mailing Address
First Line	:	1700 N WESTERN AVE UNIT A
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-5324
Country	:	US
Telephone Number	:	312-620-7733
Fax Number	:

Provider Business Practice Location Address
First Line	:	1700 N WESTERN AVE UNIT A
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-5324
Country	:	US
Telephone Number	:	312-620-7733
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	CONNIE J WOO
Credential	:	DMD
Telephone Number	:	224-612-1383

Provider Enumeration Date	:	08/10/2023
Last Update Date	:	01/05/2024

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Directions to “BRISTLE DENTAL STUDIO ” Practice Location

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