MEDICARE: DENTPOL

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	019015515	IL

General Provider Information

NPI Number	:	1558667097
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTPOL

Provider Business Mailing Address
First Line	:	7407 W IRVING PARK RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60634-2139
Country	:	US
Telephone Number	:	773-625-2626
Fax Number	:	773-625-4071

Provider Business Practice Location Address
First Line	:	7407 W IRVING PARK RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60634-2139
Country	:	US
Telephone Number	:	773-625-2626
Fax Number	:	773-625-4071

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MISS ALICJA JONIK
Credential	:	TECHNICIAN
Telephone Number	:	773-625-2626

Provider Enumeration Date	:	02/01/2011
Last Update Date	:	02/01/2011

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Directions to “DENTPOL ” Practice Location

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