MEDICARE: DENTAL PROFILE

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	:	1558532861
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL PROFILE

Provider Business Mailing Address
First Line	:	2556 W NORTH AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-5216
Country	:	US
Telephone Number	:	773-782-0014
Fax Number	:	773-782-8298

Provider Business Practice Location Address
First Line	:	2556 W NORTH AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-5216
Country	:	US
Telephone Number	:	773-782-0014
Fax Number	:	773-782-8298

Authorized Official
Title or Position	:	MANAGER
Name	:	MILAN RONCEVIC
Credential	:
Telephone Number	:	630-516-0000

Provider Enumeration Date	:	03/13/2008
Last Update Date	:	03/13/2008

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Directions to “DENTAL PROFILE ” Practice Location

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