MEDICARE: DR. ENRICO MEDINA DDS

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		IL

General Provider Information

NPI Number	:	1720184559
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ENRICO MEDINA DDS

Provider Business Mailing Address
First Line	:	2320 SIMSBURY CT
Second Line	:
City	:	NAPERVILLE
State	:	IL
Zip	:	60564-9559
Country	:	US
Telephone Number	:	630-904-4030
Fax Number	:	773-238-5713

Provider Business Practice Location Address
First Line	:	10142 S WESTERN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60643-1928
Country	:	US
Telephone Number	:	773-233-3535
Fax Number	:	773-238-5713

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

Provider Enumeration Date	:	09/16/2006
Last Update Date	:	07/08/2007

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