Provider Demographics
NPI:1033652920
Name:BAZIOTES, JOAN
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:
Last Name:BAZIOTES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7601 W IRVING PARK RD
Mailing Address - Street 2:UNIT 101
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60634-2140
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14 REVERE DR
Practice Address - Street 2:
Practice Address - City:SOUTH BARRINGTON
Practice Address - State:IL
Practice Address - Zip Code:60010-9584
Practice Address - Country:US
Practice Address - Phone:847-971-9176
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-23
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019021741122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist