Provider Demographics
NPI:1760638159
Name:BUENVENIDA, PAUL
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:BUENVENIDA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3750 N LAKE SHORE DR APT 13C
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-4229
Mailing Address - Country:US
Mailing Address - Phone:708-400-2169
Mailing Address - Fax:
Practice Address - Street 1:55 E WASHINGTON ST
Practice Address - Street 2:3001
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-2103
Practice Address - Country:US
Practice Address - Phone:312-407-9900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-18
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019023430122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist