MEDICARE: PRESTIGE DENTAL CARE, 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	013556	MO

General Provider Information

NPI Number	:	1174618045
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRESTIGE DENTAL CARE, LLC

Provider Business Mailing Address
First Line	:	2915 S BRENTWOOD BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63144-2713
Country	:	US
Telephone Number	:	314-962-6622
Fax Number	:	314-961-2288

Provider Business Practice Location Address
First Line	:	2915 S BRENTWOOD BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63144-2713
Country	:	US
Telephone Number	:	314-962-6622
Fax Number	:	314-961-2288

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. SRDJAN ILIC-SILJAK
Credential	:	DMD
Telephone Number	:	314-962-6622

Provider Enumeration Date	:	10/04/2006
Last Update Date	:	10/11/2011

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