MEDICARE: BRIAN R NUGENT 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	122300000X	Dentist	019018770	IL

General Provider Information

NPI Number	:	1639332851
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIAN R NUGENT D.D.S.

Provider Business Mailing Address
First Line	:	425 BURLINGTON AVE
Second Line	:
City	:	DOWNERS GROVE
State	:	IL
Zip	:	60515-5127
Country	:	US
Telephone Number	:	630-968-5900
Fax Number	:	630-968-5901

Provider Business Practice Location Address
First Line	:	425 BURLINGTON AVE
Second Line	:
City	:	DOWNERS GROVE
State	:	IL
Zip	:	60515-5127
Country	:	US
Telephone Number	:	630-968-5900
Fax Number	:	630-968-5901

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

Provider Enumeration Date	:	07/08/2008
Last Update Date	:	07/08/2008

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