MEDICARE: COPELAND DENTAL, INC.

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	019027730	IL

General Provider Information

NPI Number	:	1841579612
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COPELAND DENTAL, INC.

Provider Business Mailing Address
First Line	:	5334 W CULLOM AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60641-1304
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5955 W IRVING PARK RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60634-2618
Country	:	US
Telephone Number	:	708-927-5111
Fax Number	:

Authorized Official
Title or Position	:	OWNER/DENTIST
Name	:	MAUREEN LEAKE
Credential	:	D.D.S.
Telephone Number	:	708-927-5111

Provider Enumeration Date	:	08/11/2011
Last Update Date	:	08/11/2011

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