MEDICARE: SUBURBAN FAMILY DENTAL CENTER, INC.

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	019022955	IL

General Provider Information

NPI Number	:	1316074818
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUBURBAN FAMILY DENTAL CENTER, INC.

Provider Business Mailing Address
First Line	:	5214 N WESTERN AVE
Second Line	:	SUITE 303
City	:	CHICAGO
State	:	IL
Zip	:	60625-2589
Country	:	US
Telephone Number	:	773-769-8195
Fax Number	:

Provider Business Practice Location Address
First Line	:	5214 N WESTERN AVE
Second Line	:	SUITE 303
City	:	CHICAGO
State	:	IL
Zip	:	60625-2589
Country	:	US
Telephone Number	:	773-769-8195
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	LOIDA TICZON PREZA
Credential	:	D.M.D
Telephone Number	:	773-769-8195

Provider Enumeration Date	:	02/28/2007
Last Update Date	:	04/15/2012

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