MEDICARE: DIVERSEY DENTAL CENTER

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		IL

General Provider Information

NPI Number	:	1790824654
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVERSEY DENTAL CENTER

Provider Business Mailing Address
First Line	:	5300 W DIVERSEY AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60639
Country	:	US
Telephone Number	:	773-202-1500
Fax Number	:	773-202-1697

Provider Business Practice Location Address
First Line	:	5300 W DIVERSEY AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60639
Country	:	US
Telephone Number	:	773-202-1500
Fax Number	:	773-202-1697

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MS. VERONICA HERNANDEZ
Credential	:
Telephone Number	:	773-202-1500

Provider Enumeration Date	:	02/06/2007
Last Update Date	:	08/22/2020

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Directions to “DIVERSEY DENTAL CENTER ” Practice Location

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