MEDICARE: SONRISA DENTAL ON ASHLAND

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1144638560
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SONRISA DENTAL ON ASHLAND

Provider Business Mailing Address
First Line	:	1713 S ASHLAND AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-2014
Country	:	US
Telephone Number	:	630-730-3233
Fax Number	:	773-484-1205

Provider Business Practice Location Address
First Line	:	1713 S ASHLAND AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-2014
Country	:	US
Telephone Number	:	630-730-3233
Fax Number	:	773-484-1205

Authorized Official
Title or Position	:	CHIEF OPERATING OFFICER
Name	:	DR. MARY LUKASZCZYK
Credential	:
Telephone Number	:	630-730-3233

Provider Enumeration Date	:	07/29/2014
Last Update Date	:	07/29/2014

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Directions to “SONRISA DENTAL ON ASHLAND ” Practice Location

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