MEDICARE: OLIVIA LARES DDS 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	122300000X	Dentist

General Provider Information

NPI Number	:	1932451754
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OLIVIA LARES DDS PC

Provider Business Mailing Address
First Line	:	2539 N KEDZIE BLVD # 2
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-1670
Country	:	US
Telephone Number	:	773-235-3292
Fax Number	:

Provider Business Practice Location Address
First Line	:	2539 N KEDZIE BLVD # 2
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-1670
Country	:	US
Telephone Number	:	773-235-3292
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	OLIVIA LARES
Credential	:	D.D.S
Telephone Number	:	312-493-7988

Provider Enumeration Date	:	10/03/2012
Last Update Date	:	10/03/2012

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