MEDICARE: LINCOLN PARK DENTAL CARE LTD

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	019025117	IL

General Provider Information

NPI Number	:	1548436959
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LINCOLN PARK DENTAL CARE LTD

Provider Business Mailing Address
First Line	:	424 W FULLERTON PKWY
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-2812
Country	:	US
Telephone Number	:	773-404-0101
Fax Number	:	773-404-1260

Provider Business Practice Location Address
First Line	:	424 W FULLERTON PKWY
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-2812
Country	:	US
Telephone Number	:	773-404-0101
Fax Number	:	773-404-1260

Authorized Official
Title or Position	:	GENERAL DENTIST
Name	:	DR. SEONG JU KIM
Credential	:	DDS.
Telephone Number	:	773-404-0101

Provider Enumeration Date	:	05/06/2008
Last Update Date	:	05/06/2008

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