MEDICARE: DENTAL PROFESSIONALS OF ILLINOIS, 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

General Provider Information

NPI Number	:	1972925584
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL PROFESSIONALS OF ILLINOIS, P.C.

Provider Business Mailing Address
First Line	:	6631 GRAND AVE STE 1
Second Line	:
City	:	GURNEE
State	:	IL
Zip	:	60031-5284
Country	:	US
Telephone Number	:	847-281-5488
Fax Number	:

Provider Business Practice Location Address
First Line	:	6631 GRAND AVE STE 1
Second Line	:
City	:	GURNEE
State	:	IL
Zip	:	60031-5284
Country	:	US
Telephone Number	:	847-281-5488
Fax Number	:

Authorized Official
Title or Position	:	INSURANCE/CREDENTIALING
Name	:	LINDSAY BEARDEN
Credential	:
Telephone Number	:	217-540-5100

Provider Enumeration Date	:	01/16/2014
Last Update Date	:	01/16/2014

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