MEDICARE: ACCESS ORTHODONTICS OF ILLINOIS PA

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	23218	TX

General Provider Information

NPI Number	:	1740540087
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ACCESS ORTHODONTICS OF ILLINOIS PA

Provider Business Mailing Address
First Line	:	2304 W ILLINOIS AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75224-1638
Country	:	US
Telephone Number	:	214-337-7200
Fax Number	:

Provider Business Practice Location Address
First Line	:	2304 W ILLINOIS AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75224-1638
Country	:	US
Telephone Number	:	214-337-7200
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ANURAG R PATEL
Credential	:	DMD
Telephone Number	:	214-337-7200

Provider Enumeration Date	:	05/21/2012
Last Update Date	:	05/21/2012

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