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	:	1356539225
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL PROFESSIONALS OF ILLINOIS, P.C.

Provider Business Mailing Address
First Line	:	11041 W 179TH ST
Second Line	:
City	:	ORLAND PARK
State	:	IL
Zip	:	60467-9452
Country	:	US
Telephone Number	:	708-478-5093
Fax Number	:	708-478-5096

Provider Business Practice Location Address
First Line	:	11041 W 179TH ST
Second Line	:
City	:	ORLAND PARK
State	:	IL
Zip	:	60467-9452
Country	:	US
Telephone Number	:	708-478-5093
Fax Number	:	708-478-5096

Authorized Official
Title or Position	:	INS COORD
Name	:	LINDSAY BEARDEN
Credential	:
Telephone Number	:	217-540-5100

Provider Enumeration Date	:	10/04/2007
Last Update Date	:	01/07/2014

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