MEDICARE: CANDID ILLINOIS, PLLC

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry

General Provider Information

NPI Number	:	1750944252
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CANDID ILLINOIS, PLLC

Provider Business Mailing Address
First Line	:	750 N FRANKLIN ST FL STC2
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60654-6263
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	750 N FRANKLIN ST FL STC2
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60654-6263
Country	:	US
Telephone Number	:	702-738-5334
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. CHESTER LYNN HURST
Credential	:
Telephone Number	:	702-738-5334

Provider Enumeration Date	:	04/19/2019
Last Update Date	:	04/19/2019

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