MEDICARE: DR. JULIE A CHAVEZ 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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	D11399	MN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	850000116	OTHER	MN	MEDICARE PTAN
4	P00841569	OTHER	MN	MEDICARE RAILROAD PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	140122	OTHER	MN	U CARE
3	000924472	OTHER	MN	UNITED CONCORDIA
5	3AI38CH	OTHER	MN	BLUE CROSS BLUE SHIELD
6	15306	OTHER	MN	DORAL/DENTAQUEST

General Provider Information

NPI Number	:	1851364392
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JULIE A CHAVEZ DDS

Provider Business Mailing Address
First Line	:	5100 GAMBLE DR
Second Line	:	SUITE 125
City	:	ST LOUIS PARK
State	:	MN
Zip	:	55416-1521
Country	:	US
Telephone Number	:	952-465-0105
Fax Number	:	952-465-0106

Provider Business Practice Location Address
First Line	:	5100 GAMBLE DR
Second Line	:	SUITE 125
City	:	ST LOUIS PARK
State	:	MN
Zip	:	55416-1521
Country	:	US
Telephone Number	:	952-465-0105
Fax Number	:	952-465-0106

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

Provider Enumeration Date	:	02/07/2006
Last Update Date	:	10/05/2010

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