MEDICARE: PEDERSEN DENTAL GROUP 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	122300000X	Dentist	019021209	IL

General Provider Information

NPI Number	:	1841547270
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDERSEN DENTAL GROUP LTD.

Provider Business Mailing Address
First Line	:	6044 N AVONDALE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60631-3114
Country	:	US
Telephone Number	:	773-544-3512
Fax Number	:	773-887-5802

Provider Business Practice Location Address
First Line	:	6044 N AVONDALE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60631-3114
Country	:	US
Telephone Number	:	773-544-3512
Fax Number	:	773-887-5802

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. FONDA R PEDERSEN
Credential	:	D.D.S.
Telephone Number	:	773-544-3512

Provider Enumeration Date	:	08/03/2012
Last Update Date	:	08/03/2012

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