MEDICARE: UNITED DENTAL CENTERS, 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	122300000X	Dentist	019017190	IL

General Provider Information

NPI Number	:	1275834509
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UNITED DENTAL CENTERS, LTD

Provider Business Mailing Address
First Line	:	3540 E 118TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60617-7314
Country	:	US
Telephone Number	:	773-646-6262
Fax Number	:

Provider Business Practice Location Address
First Line	:	3540 E 118TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60617-7314
Country	:	US
Telephone Number	:	773-646-6262
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. KENNETH FRIED
Credential	:	DDS
Telephone Number	:	773-646-6262

Provider Enumeration Date	:	11/03/2010
Last Update Date	:	05/26/2015

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