MEDICARE: WESTERN DENTAL GROUP PC

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	021002372	IL

General Provider Information

NPI Number	:	1669899613
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WESTERN DENTAL GROUP PC

Provider Business Mailing Address
First Line	:	3935 N WESTERN AVE
Second Line	:	SUITE 1S
City	:	CHICAGO
State	:	IL
Zip	:	60618-3761
Country	:	US
Telephone Number	:	773-588-1141
Fax Number	:	773-588-1143

Provider Business Practice Location Address
First Line	:	3935 N WESTERN AVE
Second Line	:	SUITE 1S
City	:	CHICAGO
State	:	IL
Zip	:	60618-3761
Country	:	US
Telephone Number	:	773-588-1141
Fax Number	:	773-588-1143

Authorized Official
Title or Position	:	DENTIST/OWNER
Name	:	SIMONA LILIANA KATONA
Credential	:
Telephone Number	:	312-502-8073

Provider Enumeration Date	:	03/26/2014
Last Update Date	:	03/26/2014

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