MEDICARE: IRENE RENIERIS

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	1223G0001X	General Practice Dentistry	019-026735	IL

General Provider Information

NPI Number	:	1912995358
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IRENE RENIERIS

Provider Business Mailing Address
First Line	:	1945 W. WILSON AVE SUITE #5117
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640
Country	:	US
Telephone Number	:	773-588-7840
Fax Number	:	773-588-0711

Provider Business Practice Location Address
First Line	:	1945 W. WILSON SUITE #5117
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640
Country	:	US
Telephone Number	:	773-588-7840
Fax Number	:	773-588-0711

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

Provider Enumeration Date	:	10/10/2005
Last Update Date	:	12/27/2023

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