MEDICARE: WASAN BALOCH

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	019030247	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1700269974
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WASAN BALOCH

Provider Business Mailing Address
First Line	:	8908 MIDDLETON ROAD
Second Line	:
City	:	DARIEN
State	:	IL
Zip	:	60561
Country	:	US
Telephone Number	:	630-915-7863
Fax Number	:

Provider Business Practice Location Address
First Line	:	7250 S CICERO AVE
Second Line	:	UNIT F
City	:	CHICAGO
State	:	IL
Zip	:	60629-5849
Country	:	US
Telephone Number	:	708-496-8896
Fax Number	:

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

Provider Enumeration Date	:	07/07/2015
Last Update Date	:	07/07/2015

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Directions to “ WASAN BALOCH ” Practice Location

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