MEDICARE: NORTH AVE. DENTAL PARTNERS P.C.

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	019029595	IL
2	1223G0001X	General Practice Dentistry	019017117	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1477744043	OTHER	IL	INDIVIDUAL NPI

General Provider Information

NPI Number	:	1942653324
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTH AVE. DENTAL PARTNERS P.C.

Provider Business Mailing Address
First Line	:	26 WYCHWOOD LN
Second Line	:
City	:	SOUTH BARRINGTON
State	:	IL
Zip	:	60010-6122
Country	:	US
Telephone Number	:	224-517-3474
Fax Number	:

Provider Business Practice Location Address
First Line	:	7020 W NORTH AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60707-4306
Country	:	US
Telephone Number	:	773-745-8300
Fax Number	:	773-745-8385

Authorized Official
Title or Position	:	PRESIDENT/DENTIST
Name	:	DR. VESNA S SUTTER
Credential	:	DDS
Telephone Number	:	224-517-3474

Provider Enumeration Date	:	07/20/2016
Last Update Date	:	02/04/2019

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