Provider Demographics
NPI:1356546840
Name:VALCOURT EWA, MARILYS (DDS, MPH)
Entity type:Individual
Prefix:DR
First Name:MARILYS
Middle Name:
Last Name:VALCOURT EWA
Suffix:
Gender:F
Credentials:DDS, MPH
Other - Prefix:
Other - First Name:GENTLE
Other - Middle Name:DENTAL
Other - Last Name:CENTER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2917 W 63RD ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60629-2729
Mailing Address - Country:US
Mailing Address - Phone:773-476-8217
Mailing Address - Fax:773-476-8251
Practice Address - Street 1:2917 W 63RD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-2729
Practice Address - Country:US
Practice Address - Phone:773-476-8217
Practice Address - Fax:773-476-8251
Is Sole Proprietor?:No
Enumeration Date:2007-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL158077525126OtherHUMANA TDC
IL001075OtherCOMPDENT
IL1001783Medicaid
IL013043OtherFIRST COMMONWEALTH
IL0000779OtherDENTAL NETWORK OF AMERICA