MEDICARE: FLOSS DENTAL STUDIO PC

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	332BC3200X	Customized Equipment (DME)
2	122300000X	Dentist	019025071	IL

General Provider Information

NPI Number	:	1851785224
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FLOSS DENTAL STUDIO PC

Provider Business Mailing Address
First Line	:	PO BOX 221018
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-0008
Country	:	US
Telephone Number	:	773-235-2322
Fax Number	:	773-235-2332

Provider Business Practice Location Address
First Line	:	924 N DAMEN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-4948
Country	:	US
Telephone Number	:	773-235-2322
Fax Number	:	773-235-2332

Authorized Official
Title or Position	:	OWNER/PRES/DENTIST
Name	:	DR. MICHELLE ANN RADEKA
Credential	:	DMD
Telephone Number	:	773-235-2322

Provider Enumeration Date	:	03/24/2015
Last Update Date	:	04/23/2015

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