MEDICARE: LTC DENTAL III 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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1467169409
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LTC DENTAL III LLC

Provider Business Mailing Address
First Line	:	2314 S ROUTE 59 STE 384
Second Line	:
City	:	PLAINFIELD
State	:	IL
Zip	:	60586-7756
Country	:	US
Telephone Number	:	888-970-3400
Fax Number	:	888-456-3812

Provider Business Practice Location Address
First Line	:	1314 S 1ST ST # 276
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53204-2405
Country	:	US
Telephone Number	:	888-970-3400
Fax Number	:	888-456-3812

Authorized Official
Title or Position	:	OWNER
Name	:	TARA ROBINSON
Credential	:
Telephone Number	:	407-375-3003

Provider Enumeration Date	:	10/31/2022
Last Update Date	:	04/06/2023

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Directions to “LTC DENTAL III LLC ” Practice Location

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