MEDICARE: APOLLO DENTAL CLINIC, LLC

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	122300000X	Dentist	019026293	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1083937742
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	APOLLO DENTAL CLINIC, LLC

Provider Business Mailing Address
First Line	:	6121 WASHINGTON ST
Second Line	:	SUITE 203
City	:	GURNEE
State	:	IL
Zip	:	60031-5305
Country	:	US
Telephone Number	:	630-267-4205
Fax Number	:	630-477-0447

Provider Business Practice Location Address
First Line	:	6121 WASHINGTON ST
Second Line	:	SUITE 203
City	:	GURNEE
State	:	IL
Zip	:	60031-5305
Country	:	US
Telephone Number	:	630-267-4205
Fax Number	:	630-477-0447

Authorized Official
Title or Position	:	MEMBER
Name	:	DR. SUMRANA S AHMED
Credential	:	DDS
Telephone Number	:	630-267-4205

Provider Enumeration Date	:	03/10/2010
Last Update Date	:	03/10/2010

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