MEDICARE: LRC PERIODONTICS AND IMPLANTS, 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	1223P0300X	Periodontics	019.027682	IL

General Provider Information

NPI Number	:	1386997906
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LRC PERIODONTICS AND IMPLANTS, LLC

Provider Business Mailing Address
First Line	:	1099 BELT LINE RD
Second Line	:	SUITE A
City	:	COLLINSVILLE
State	:	IL
Zip	:	62234-4380
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1099 BELT LINE RD
Second Line	:	SUITE A
City	:	COLLINSVILLE
State	:	IL
Zip	:	62234-4380
Country	:	US
Telephone Number	:	402-943-7711
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PERIODONTIST
Name	:	DR. LAURA RICHARDS CAPATI
Credential	:	DMD, MS
Telephone Number	:	402-943-7711

Provider Enumeration Date	:	10/19/2012
Last Update Date	:	10/19/2012

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