1740268416 NPI number — SILVIO J CAMODECA DDS DN

Table of content: (NPI 1740268416)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740268416 NPI number — SILVIO J CAMODECA DDS DN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SILVIO J CAMODECA DDS DN
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
AVENUE DENTAL CLINIC & LAB
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1740268416
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/30/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3518 W FULLERTON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60647
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-278-0334
Provider Business Mailing Address Fax Number:
773-365-0314

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3518 W FULLERTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60647
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-278-0334
Provider Business Practice Location Address Fax Number:
773-365-0314
Provider Enumeration Date:
01/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CAMODECA
Authorized Official First Name:
SILVIO
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
773-278-0334

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  019015351 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 122300000X , with the licence number: 12010C12A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 175F00000X , with the licence number: NAT1000255 , registered in the state of DC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 204D00000X , with the licence number: 181000299 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: NAT1000255 . This is a "NATUROPATHY" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: 12010612A . This is a "DENTISTRY" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 019015351 . This is a "DENTISTRY" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 181000299 . This is a "NAPRAPATH" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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