MEDICARE: DR. STEVEN VONGLUEKIAT 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	122300000X	Dentist	019.027344	IL

General Provider Information

NPI Number	:	1902001613
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STEVEN VONGLUEKIAT DDS

Provider Business Mailing Address
First Line	:	821 7TH AVE
Second Line	:
City	:	LA GRANGE
State	:	IL
Zip	:	60525-2910
Country	:	US
Telephone Number	:	312-791-0920
Fax Number	:	312-842-5338

Provider Business Practice Location Address
First Line	:	2959 S WALLACE ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616-3034
Country	:	US
Telephone Number	:	312-791-0920
Fax Number	:

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

Provider Enumeration Date	:	06/20/2007
Last Update Date	:	10/16/2012

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