MEDICARE: CRYSTAL LAKE PEDIATRIC DENTAL LTD.

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	1223P0221X	Pediatric Dentistry		IL

General Provider Information

NPI Number	:	1043311681
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRYSTAL LAKE PEDIATRIC DENTAL LTD.

Provider Business Mailing Address
First Line	:	820 E TERRA COTTA AVE
Second Line	:	111
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60014-3649
Country	:	US
Telephone Number	:	815-356-7960
Fax Number	:	815-356-8051

Provider Business Practice Location Address
First Line	:	820 E TERRA COTTA AVE
Second Line	:	111
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60014-3649
Country	:	US
Telephone Number	:	815-356-7960
Fax Number	:	815-356-8051

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ANTHONY LOUIS MINUTILLO
Credential	:	DDS,MSD
Telephone Number	:	815-356-7960

Provider Enumeration Date	:	09/26/2006
Last Update Date	:	08/22/2020

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Practice Location Address:

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Directions to “CRYSTAL LAKE PEDIATRIC DENTAL LTD. ” Practice Location

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