MEDICARE: MRS. TONI L DAMORE BS RDHMED

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	124Q00000X	Dental Hygienist		IL

General Provider Information

NPI Number	:	1760564991
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TONI L DAMORE BS RDHMED

Provider Business Mailing Address
First Line	:	1973 ALPINE CT
Second Line	:
City	:	GURNEE
State	:	IL
Zip	:	60031-1782
Country	:	US
Telephone Number	:	847-662-2044
Fax Number	:

Provider Business Practice Location Address
First Line	:	1160 PARK AVE W
Second Line	:	SUITE 6E
City	:	HIGHLAND PARK
State	:	IL
Zip	:	60035-2230
Country	:	US
Telephone Number	:	847-433-0320
Fax Number	:	847-433-5952

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

Provider Enumeration Date	:	10/19/2006
Last Update Date	:	07/08/2007

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