Healthcare Provider Details

I. General information

NPI: 1295254589
Provider Name (Legal Business Name): WEST AURORA FAMILY DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2017
Last Update Date: 09/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1940 W GALENA BLVD STE 7
AURORA IL
60506-4482
US

IV. Provider business mailing address

1699 E WOODFIELD RD STE 102
SCHAUMBURG IL
60173-4955
US

V. Phone/Fax

Practice location:
  • Phone: 630-339-3172
  • Fax:
Mailing address:
  • Phone: 630-339-3172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019029852
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019025570
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019026827
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019031185
License Number StateIL

VIII. Authorized Official

Name: DR. ALAN J ACIERNO
Title or Position: MANAGER
Credential: DDS
Phone: 630-339-3172