MEDICARE: DENTAL PROFESSIONALS OF ILLINOIS, P.C.

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

General Provider Information

NPI Number	:	1346651577
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL PROFESSIONALS OF ILLINOIS, P.C.

Provider Business Mailing Address
First Line	:	1490 DOUGLAS RD
Second Line	:
City	:	OSWEGO
State	:	IL
Zip	:	60543-5106
Country	:	US
Telephone Number	:	331-725-7669
Fax Number	:

Provider Business Practice Location Address
First Line	:	1490 DOUGLAS RD
Second Line	:
City	:	OSWEGO
State	:	IL
Zip	:	60543-5106
Country	:	US
Telephone Number	:	331-725-7669
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING COORDINATOR
Name	:	LINDSAYL BEARDEN
Credential	:
Telephone Number	:	217-540-5100

Provider Enumeration Date	:	05/09/2014
Last Update Date	:	05/09/2014

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