MEDICARE: PRAIRIE ORTHODONTICS PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	06006486	IL

General Provider Information

NPI Number	:	1033284831
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRAIRIE ORTHODONTICS PC

Provider Business Mailing Address
First Line	:	6121 WASHINGTON ST
Second Line	:	SUITE 204
City	:	GURNEE
State	:	IL
Zip	:	60031
Country	:	US
Telephone Number	:	847-249-8800
Fax Number	:	847-249-8869

Provider Business Practice Location Address
First Line	:	6121 WASHINGTON ST
Second Line	:	SUITE 204
City	:	GURNEE
State	:	IL
Zip	:	60031
Country	:	US
Telephone Number	:	847-249-8800
Fax Number	:	847-249-8869

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. BRIDGET O MUELLER
Credential	:
Telephone Number	:	847-249-8800

Provider Enumeration Date	:	11/21/2006
Last Update Date	:	08/22/2020

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