Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 019.029667 | IL |
N | 1223P0221X | Pediatric Dentist | 62834 | CA |
NPI | 1083929475 |
---|---|
Provider Name | Dr. David Michael Avenetti |
First Address | Chicago, IL 60611 |
Second Address | Chicago, IL 60612-7210 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/08/2010 |
Last Update Date | 22/11/2013 |