Healthcare Provider Details

I. General information

NPI: 1972904282
Provider Name (Legal Business Name): MEADOW LAKE DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2014
Last Update Date: 09/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3941 75TH ST SUITE 102
AURORA IL
60504-7924
US

IV. Provider business mailing address

129 S ROSELLE RD STE 102
SCHAUMBURG IL
60193-5538
US

V. Phone/Fax

Practice location:
  • Phone: 630-851-5130
  • Fax: 630-851-5739
Mailing address:
  • Phone: 630-339-3172
  • Fax: 847-891-6775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number019021506
License Number StateIL

VIII. Authorized Official

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