MEDICARE: PERFECT CHOICE DENTAL, P.C.

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	122300000X	Dentist	019022498	IL

General Provider Information

NPI Number	:	1700978772
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PERFECT CHOICE DENTAL, P.C.

Provider Business Mailing Address
First Line	:	284 MEMORIAL COURT
Second Line	:	SUITE A
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60014-6231
Country	:	US
Telephone Number	:	815-477-3700
Fax Number	:	815-477-4806

Provider Business Practice Location Address
First Line	:	284 MEMORIAL COURT
Second Line	:	SUITE A
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60014-6231
Country	:	US
Telephone Number	:	815-477-3700
Fax Number	:	815-477-4806

Authorized Official
Title or Position	:	OWNER/ PRESIDENT
Name	:	MR. BRIAN P. OVERMYER
Credential	:	D.D.S.
Telephone Number	:	815-477-3700

Provider Enumeration Date	:	09/28/2006
Last Update Date	:	05/23/2011

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