MEDICARE: FAMILIA DENTAL RIVER GLEN 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	1223G0001X	General Practice Dentistry
2	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1154794584
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILIA DENTAL RIVER GLEN LLC

Provider Business Mailing Address
First Line	:	2050 EAST ALGONQUIN ROAD
Second Line	:	SUITE 610
City	:	SCHAUMBURG
State	:	IL
Zip	:	60173-4166
Country	:	US
Telephone Number	:	847-453-7396
Fax Number	:	847-453-7396

Provider Business Practice Location Address
First Line	:	142 E CAPITOL DR
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53212-1206
Country	:	US
Telephone Number	:	414-444-1823
Fax Number	:	414-963-1163

Authorized Official
Title or Position	:	CREDENTIALING & PAYER RELATIONS MAN
Name	:	MR. BRANDON ALEXANDER TAYLOR
Credential	:	CPCS
Telephone Number	:	847-453-7396

Provider Enumeration Date	:	11/06/2015
Last Update Date	:	06/30/2021

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53212-1206

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