MEDICARE: OLD TOWN DENTAL ASSOCIATES LTD

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		IL

General Provider Information

NPI Number	:	1801859137
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OLD TOWN DENTAL ASSOCIATES LTD

Provider Business Mailing Address
First Line	:	1397 MAIN ST
Second Line	:	P.O.BOX 37
City	:	CRETE
State	:	IL
Zip	:	60417-2951
Country	:	US
Telephone Number	:	708-672-5353
Fax Number	:

Provider Business Practice Location Address
First Line	:	1397 MAIN ST
Second Line	:
City	:	CRETE
State	:	IL
Zip	:	60417-2951
Country	:	US
Telephone Number	:	708-672-5353
Fax Number	:

Authorized Official
Title or Position	:	PRES
Name	:	DR. ANGELA R. BAMMANN
Credential	:	DMD
Telephone Number	:	708-672-5353

Provider Enumeration Date	:	04/08/2006
Last Update Date	:	08/22/2020

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