MEDICARE: PREMIER DENTAL CLINC, LLC

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	019024846	IL

General Provider Information

NPI Number	:	1811168800
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIER DENTAL CLINC, LLC

Provider Business Mailing Address
First Line	:	7345 W 25TH ST
Second Line	:
City	:	NORTH RIVERSIDE
State	:	IL
Zip	:	60546-1409
Country	:	US
Telephone Number	:	708-447-0900
Fax Number	:

Provider Business Practice Location Address
First Line	:	7345 W 25TH ST
Second Line	:
City	:	NORTH RIVERSIDE
State	:	IL
Zip	:	60546-1409
Country	:	US
Telephone Number	:	708-447-0900
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR DOCTOR CREDENTIALING
Name	:	PHIL KURAL
Credential	:
Telephone Number	:	312-274-4526

Provider Enumeration Date	:	03/18/2008
Last Update Date	:	03/20/2020

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